Multiple myeloma in the elderly

Diagnostic and Prognostic Value of PACAP in Multiple Myeloma

Pituitary adenylate cyclase-activating polypeptide (PACAP) is a multifunctional neuropeptide with well-known anti-inflammatory, antioxidant, antitumor, and immunomodulatory effects. PACAP regulates the production of various proinflammatory factors and may influence the complex cytokine network of the bone marrow microenvironment altered by plasma cells, affecting the progression of multiple myeloma (MM) and the development of end-organ damage. The aim of our study was to investigate the changes in PACAP-38 levels in patients with MM to explore its value as a potential biomarker in this disease. We compared the plasma PACAP-38 levels of MM patients with healthy individuals by ELISA method and examined its relationship with various MM-related clinical and laboratory parameters. Lower PACAP-38 levels were measured in MM patients compared with the healthy controls, however, this difference vanished if the patient achieved any response better than partial response. In addition, lower peptide levels were found in elderly patients. Significantly higher PACAP-38 levels were seen in patients with lower stage, lower plasma cell infiltration in bone marrow, lower markers of tumor burden in serum, lower total urinary and Bence-Jones protein levels, and in patients after lenalidomide therapy. Higher PACAP-38 levels in newly diagnosed MM patients predicted longer survival and a higher probability of complete response to treatment. Our findings confirm the hypothesis that PACAP plays an important role in the pathomechanism of MM. Furthermore, our results suggest that PACAP might be used as a valuable, non-invasive, complementary biomarker in diagnosis, and may be utilized for prognosis prediction and response monitoring.

The adverse prognostic impact of advanced age in multiple myeloma

The adverse prognostic impact of advanced age in multiple myeloma is multi-factorial. In this review we explore the various contributory factors to this phenomenon. These include general biological and psychosocial factors, which impact on cancer in the elderly population such as the presence of multiple co morbidities and poor performance status at diagnosis and variation in patient's expectations of treatment. Factors specific to myeloma include the ability to deliver optimum therapy in older patients and the impact of this on disease response, possible biological differences of myeloma in older patients, and how these various factors impact on the efficacy of conventional-dose, high-dose (HDT) and newer disease modifying therapies. Selected elderly patients can gain equal benefit to younger patients from effective therapies such as HDT. However, the use of specific assessment tools for the elderly, apart from chronological age, should be used to select elderly patients who will benefit. Future testing of newer therapies in patients with myeloma must include older patients, who will make up an increasing proportion of the myeloma population in the future and should incorporate assessment of effect of these therapies on quality of life.

New generation pharmacotherapy in elderly multiple myeloma patients

BACKGROUND

Observational databases have demonstrated that the overall prognosis of multiple myeloma patients has markedly improved over the past decade, yet the greatest strides have been attained in younger rather than older patients.

OBJECTIVE

To review recent clinical trials that include new generation agents (thalidomide, lenalidomide and bortezomib) and autologous stem cell transplantation in older multiple myeloma patients.

RESULTS

Conventional regimens such as melphalan plus prednisone can be improved with the addition of thalidomide or bortezomib: more patients attain complete and near-complete remission, and progression-free survival rates are nearly doubled. In addition, autologous hematopoietic stem cell transplantation studies show that this treatment approach can be used successfully in selected older myeloma patients in whom the toxicity profile of autotransplant and resulting overall survival may be similar to that obtained in the younger patient group.

CONCLUSIONS

In the advanced-age population, implementation of new therapies results in significant benefits in older as well as younger patients.

Modern treatment options for elderly patients with multiple myeloma

Multiple myeloma, an incurable malignancy of plasma cells, is a disease of the elderly. In younger patients, significant therapeutic progress has been achieved, but survival outcomes remain unacceptably low in older adults with multiple myeloma. Diverse factors, including comorbidity, performance status, decreased physiologic reserve, and potential undertreatment, contribute to these poor outcomes. Unfortunately, many clinical trials are designed to exclude elderly patients with coexisting diseases, so only limited data are available and no guidelines exist on how to treat this challenging and growing myeloma population. A broader range of therapeutic options has become available within the last few years, including chemotherapy with either established or newly available drugs, immunomodulators, and high-dose treatment with stem cell support (autologous as well as allogeneic). In this review, we discuss the data available from clinical trials investigating antineoplastic treatment of elderly multiple myeloma patients.

Current therapies for multiple myeloma

Multiple myeloma is an incurable B-cell malignancy of plasma cells but also a highly treatable disease. This article is an overview of multiple myeloma and its current therapies, with emphasis on bortezomib and lenalidomide. Important nursing considerations related to the management of common adverse events are also described.

The Changing Treatment Paradigm in Patients With Newly Diagnosed Multiple Myeloma: Implications for Nursing

PURPOSE/OBJECTIVES

To review the changing treatment paradigm for newly diagnosed multiple myeloma and its implications for nursing.

DATA SOURCES

Journal articles, textbooks, published research data.

DATA SYNTHESIS

The treatment approaches to newly diagnosed multiple myeloma are varied, and no consensus exists about the best choice of induction therapy prior to high-dose chemotherapy with autologous stem cell transplantation. Novel therapies that have shown strong clinical activity in patients with relapsed or refractory myeloma currently are being explored as first-line therapy with associated higher incidence of serious complications.

CONCLUSIONS

Novel approaches in the treatment of newly diagnosed multiple myeloma may lead to better overall patient survival. Research is ongoing to find ways to improve progression-free and overall survival in patients with multiple myeloma.

IMPLICATIONS FOR NURSING

Oncology nurses play vital roles in the assessment and monitoring of serious complications associated with various therapies for patients with newly diagnosed multiple myeloma. Key responsibilities include safe and effective administration of complex chemotherapeutic regimens, management of side effects, patient and family education, and coordination of a multidisciplinary approach.

Autologous stem cell transplantation in elderly multiple myeloma patients over the age of 70 years

The feasibility and efficacy of autologous stem cell transplantation (auto-SCT) in patients aged > or = 70 years was analysed. Newly diagnosed (n = 34) and refractory multiple myeloma (n = 36) patients were studied. The median age was 72 years (range: 70-82.6). CD34+ cells were mobilized with chemotherapy and granulocyte colony-stimulating factor (G-CSF) (n = 35) or G-CSF alone (n = 35), yielding medians of 11.8 x 10(6) versus 8 x 10(6) cells/kg respectively (P = 0.007). Because of excessive mortality (16%) in the first 25 patients who received melphalan 200 mg/m2 (MEL-200), the dose was subsequently decreased to 140 mg/m2 (MEL-140). Median times to absolute neutrophil count (ANC) > 0.5 x 10(9)/l and to platelets > 20 x 10(9)/l were 11 and 13 d respectively. Thirty-one patients (44%) received tandem auto-SCT. Complete remission (CR) was 20% after the first SCT and 27% after tandem SCT. Median CR duration was 1.5 years and was significantly longer for patients with < or = 12 months of prior chemotherapy (2.6 versus 1.0 years, P = 0.0008). The 3-year event-free survival (EFS) and overall survival (OS) (+ standard error, SE) were projected at 20% + 9% and 31% + 10% respectively. Tandem SCTs positively affected EFS (4.0 versus 0.7 years; P = 0.003) and OS (4.0 versus 1.4 years; P = 0.02) compared with single auto-SCT. In conclusion, MEL-140 is less toxic and appears equally as efficacious as MEL-200 in elderly patients. The benefits of tandem SCT in this patient population need further evaluation in a randomized trial.

Multiple myeloma in elderly patients: presenting features and outcome

Few studies have been performed regarding multiple myeloma (MM) in elderly patients. We report a retrospective series of 130 unselected patients with MM aged 75 yr or more at diagnosis. Presenting features were identical to those reported in younger patients, except for a higher rate of infection. Heavy comorbidity was characteristic of unselected geriatric patients. Ninety-four patients received conventional chemotherapy. The response rate was 62%. Treatment toxicity was mild. Median survival was 22 months. Durie-Salmon (DS) clinical stages II and III MM were severe and often led to death, while significantly more patients with DS stage I MM died from unrelated causes (p<0.0001). Univariate analysis showed that age > or = 85 yr, performance status > or = 2, creatinine level > or = 120 micromol/l, beta 2 microglobulin level > 4 mg/l, C-reactive protein level > 6 mg/l, platelet count < 100 x 10(9)/l, presence of infection and lack of response to chemotherapy were adverse prognostic factors for survival. In Cox multivariate regression analysis, age > or = 85 yr (p<0.0001), performance status > or = 2 (p<0.0001) and creatinine level > or = 120 micromol/l (p<0.0001) were independent factors in predicting short survival. This study provides evidence that in patients with symptomatic MM age should not be considered as a major obstacle to active treatment. Prospective clinical trials are needed in this population of patients and should include an assessment of quality of life.

Racial differences in the prevalence of monoclonal gammopathy in a community-based sample of the elderly

PURPOSE

To determine if there is an increased prevalence of monoclonal gammopathy in elderly blacks compared with whites, analogous to the difference in incidence of multiple myeloma reported for the two racial groups and to confirm age and gender relationships.

PATIENTS AND METHODS

Subjects were from the Duke Established Populations for the Epidemiologic Study of the Elderly, selected on the basis of stratified random household sampling. Blacks were oversampled to allow for increased statistical precision in racial comparisons. In all, 1,732 subjects (aged > 70 years) consented to blood drawing and constitute the sample for this study. Monoclonal immunoglobulins were determined by agarose gel electrophoresis and immunofixation.

RESULTS

One hundred six subjects (6.1%) had a monoclonal gammopathy. There was a greater than twofold difference in prevalence between blacks (8.4%) and whites (3.8%) (P < 0.001); monoclonal gammopathy prevalence increased with age, and was greater in men than women. Those with monoclonal gammopathy did not differ from those without in socioeconomic status, urban/rural residence, or education. The presence of monoclonal gammopathy was not associated with any specific diseases nor with impaired functional status. There was a slight increase in serum creatinine levels and decrease in hemoglobin and albumin levels in patients with monoclonal gammopathy, but no difference in interleukin-6 (IL-6) levels. Moreover, IL-6 levels were not correlated significantly with the level of monoclonal protein.

CONCLUSION

Prevalence of monoclonal gammopathy is significantly greater among blacks than whites in a community-based sample, in approximately the same ratio that multiple myeloma has been reported in the two groups. Given the absence of correlation with environmental factors, there may be a biological racial difference in susceptibility to an early event in the carcinogenic process leading to multiple myeloma.

Therapeutic management of hematological malignancies in elderly patients. Biological and clinical considerations. Part IV: Multiple myeloma and Waldenström's macroglobulinemia

Following recent data on multiple myeloma (MM) in the literature, a possible model of myeloma development, involving different cytokine signals, is advanced, and the prognostic significance of two principle staging systems is evaluated. Different therapeutic approaches to MM have been employed, consisting of either treatment with only melphalan and prednisone, or combination chemotherapy, especially in patients with a poor prognosis. However, for the initial therapy, melphalan plus prednisone in doses that compensate for individual variation in drug absorption still appears the best choice in the vast majority of MM patients. The main clinical and hematological features which distinguish Waldenström's macroglobulinemia from MM are described, as are the criteria which should be used in choosing the most appropriate treatment based, when necessary, on chemotherapy with standard alkylating agents, as well as on the new nucleoside analogues, and repeated courses of plasmapheresis.

Multiple myeloma

OBJECTIVES

To review the epidemiology, pathogenesis, clinical features, diagnosis, treatment, and nursing management of multiple myeloma.

DATA SOURCES

Review articles, research studies, and book chapters related to multiple myeloma.

CONCLUSIONS

Despite insights into the immunobiology of multiple myeloma and the advances in intensive therapy and supportive care, multiple myeloma remains an incurable disease. Patients will experience chronic and acute symptomatic episodes throughout the course of their disease.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses can assist patients with multiple myeloma and their families to manage both the disease and treatment related symptoms and to improve their overall quality of life. Specific nursing assessments can provide early recognition of complications, such as hypercalcemia and spinal cord compression.