Impact of Frailty on Outcomes after Chimeric Antigen Receptor T Cell Therapy for Patients with Relapsed/Refractory Multiple Myeloma

Outcomes of frail patients undergoing high-dose chemotherapy and autologous stem cell transplantation for multiple myeloma

In patients with multiple myeloma (MM) not-eligible for autologous haematopoietic cell transplantation (autoHCT), a simplified frailty index (SFI) identifies frail patients at risk for poor outcomes, but data are limited for transplant-eligible patients. In this registry-based retrospective study, we used an adapted version of the SFI to determine the prevalence of frailty in patients ≥65 years of age with MM undergoing autoHCT. Out of 5563 patients, 37.9% of patients were classified as frail and although they had increased non-relapse mortality (NRM) and inferior overall survival, the NRM at 100 days remained low (<2%) compared with non-frail patients.

License for a CAR T: Examining patient eligibility

Chimeric antigen receptor (CAR) T-cell therapy has transformed the treatment landscape of lymphoma and is now approved by the FDA for multiple indications. Given that the indications for CAR T-cell therapy are expanding, a larger patient population will be eligible to receive this treatment in the coming years. Pivotal clinical trials leading to FDA approval of CAR T-cell products required patients to have adequate organ function and good performance status. In the real world, however, the patient population eligible for CAR T-cell therapy includes patients who are older, frail, have poor performance status, and have multiple comorbidities. Studies have shown that CAR T-cell therapy is relatively safe and tolerable in such frail patients, however, there is no agreed upon consensus or guidelines to assess eligibility for CAR T-cell therapy at this moment. Gaining further insight into such patient populations will be vital in order to safely provide and expand access to CAR T-cell therapy.

Current Novel Targeted Therapeutic Strategies in Multiple Myeloma

Multiple myeloma (MM) is a hematologic malignancy caused by the clonal expansion of immunoglobulin-producing plasma cells in the bone marrow and/or extramedullary sites. Common manifestations of MM include anemia, renal dysfunction, infection, bone pain, hypercalcemia, and fatigue. Despite numerous recent advancements in the MM treatment paradigm, current therapies demonstrate limited long-term effectiveness and eventual disease relapse remains exceedingly common. Myeloma cells often develop drug resistance through clonal evolution and alterations of cellular signaling pathways. Therefore, continued research of new targets in MM is crucial to circumvent cumulative drug resistance, overcome treatment-limiting toxicities, and improve outcomes in this incurable disease. This article provides a comprehensive overview of the landscape of novel treatments and emerging therapies for MM grouped by molecular target. Molecular targets outlined include BCMA, GPRC5D, FcRH5, CD38, SLAMF7, BCL-2, kinesin spindle protein, protein disulfide isomerase 1, peptidylprolyl isomerase A, Sec61 translocon, and cyclin-dependent kinase 6. Immunomodulatory drugs, NK cell therapy, and proteolysis-targeting chimera are described as well.

Effects on the Physical Functioning of Two Exercise Interventions in Patients with Multiple Myeloma: A Pilot Feasibility Study

Because of the high prevalence of bone destruction in patients with multiple myeloma (MM), physical exercise is oftentimes discouraged by healthcare providers. The goal of this prospective trial was to investigate the feasibility of two six-month exercise interventions in patients with MM (N = 42): a remotely prompted home-based walking intervention or a supervised strength training intervention. Physical function and pain were assessed with the Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Short Form raw score, a six-minute walk test (6 MWT), a 30-second sit-to-stand test (30 SST), a timed up-and-go (TUG) test, a visual analog scale (VAS) for pain, handheld dynamometer tests, heart rate at rest, blood oxygen saturation at rest, and body mass index. No intervention-related serious adverse events were observed. Adverse events mostly affected the musculoskeletal system. In the resistance training group (n = 24), patients showed significant improvements in AM-PAC, TUG, 6 MWT, and 30 SST, with all effects but the 6 MWT sustained six months after the intervention. The walking group (n = 18) saw improvements in the AM-PAC, TUG, 6 MWT, and 30 SST, with a sustained change in the AM-PAC and TUG. This trial shows the feasibility of both exercise interventions with a sustained beneficial effect on the physical functioning of a six-month strength training intervention and, to a lesser extent, a six-month unsupervised walking intervention. A larger study building on these findings is currently underway.

Clinical Outcomes and Toxicity in Older Adults Receiving Chimeric Antigen Receptor T Cell Therapy

Chimeric antigen receptor T cell therapy (CAR-T) has transformed the treatment landscape for adults with relapsed/refractory hematologic malignancies, but few studies have examined outcomes in older adults. We aimed to evaluate clinical outcomes and treatment toxicity in older adults receiving CAR-T for hematologic malignancies and to describe outcomes and toxicities in older adults age 75+ years compared to those age 65 to 74 years. We conducted a retrospective analysis of 141 adult patients age 65+ years (46.1% age 75+ years) who received commercial CAR-T at Massachusetts General Hospital between December 2017 and June 2023. We abstracted clinical outcomes from a review of the electronic health record, including (1) toxicity (ie, cytokine release syndrome [CRS] and immune effector cell-associated neurotoxicity syndrome [ICANS]); (2) health care utilization; (3) overall survival (OS); and (4) event-free survival (EFS). We analyzed the association of age (65 to 74 years versus 75+ years) with toxicity and health care utilization using the Mann-Whitney U test for continuous variables and the Fisher exact test for categorical variables. We examined the association of age with OS and EFS using multivariable Cox regression, controlling for covariates. The median patient age was 77 years (range, 75 to 91 years) in the 75+ year group and 69 years (ranges, 65 to 74 years) in the 65 to 74 year group. There were no statistically significant differences between the 75+ year group and the 65 to 74 year group in the rates of CRS (75.4% versus 84.2%; P = .21), grade 3+ CRS (1.5% versus 6.6%; P = .24), ICANS (38.5% versus 48.7%; P = .24), grade 3+ ICANS (16.9% versus 21.1%; P = .49), or infections (23.1% versus 29.0%; P = .45). There were no significant between-group differences in hospital readmissions within 30 days of CAR-T (10.8% versus 21.1%; P = .11), intensive care unit admissions within 30 days of CAR-T (7.7% versus 9.2%; P = 1.000), or median hospital length of stay (13 days versus 14 days; P = .29) among age groups. In a multivariable Cox regression analysis controlling for CAR-T product, Eastern Cooperative Oncology Group Performance Status, lactate dehydrogenase level, bridging therapy use, and history of deep venous thromboembolism, age 75+ years was not associated with OS (hazard ratio [HR], .95; P = .86) or EFS (HR, 1.28; P = .30). We identified favorable OS and toxicity outcomes across age categories in older adults receiving CAR-T for B cell non-Hodgkin lymphoma or multiple myeloma, underscoring that age alone is not a contraindication for CAR-T.