Treatment of Elderly Patients With Multiple Myeloma

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There were several clinical trials assessing newer agents for the treatment of elderly patients (>75 years) with multiple myeloma presented at the 2014 ASH Annual Meeting, explains Sundar Jagannath, MD. These studies were looking specifically at newer immunomodulatory agents and proteasome inhibitors. The traditional treatment for these patients has been melphalan, prednisone, and thalidomide, suggesting the exploration of these novel therapies could offer a substantial benefit, Jagannath notes.

The FIRST trial examined the efficacy of lenalidomide and dexamethasone with the longstanding standard of care, melphalan, prednisone, and thalidomide (MPT), explains Shaji Kumar, MD. Lenalidomide and dexamethasone were administered as either fixed duration for 18 months or continually until the disease returned.

Data thus far suggest that continuously administering lenalidomide and dexamethasone in older patients until the disease returns is superior to MPT as initial treatment. The median progression-free survival (PFS) with the continuous lenalidomide combination was 21.2 months compared with 19.4 months in the 18-month arm and 19.2 months with MPT for patients over age 75 with multiple myeloma. The 4-year OS rate was 47% in both lenalidomide arms versus 39% with MPT.

Sagar Lonial, MD, and Jeffrey Zonder, MD, agree that the lenalidomide and dexamethasone regimen studied in the FIRST trial is a reasonable choice in the older population. James R. Berenson, MD, considers not only age, but disease characteristics and patient comorbidities when treating new patients, noting that he sees many robust 80-year-olds who are treated quite similarly to his younger patients.

Patients younger than age 75 in the FIRST trial also demonstrated a marked improvement in outcomes with lenalidomide and dexamethasone. For those treated with the continuous dose, the PFS was 27.4 versus 21.3 and 21.8 months, with the 18-month dose and MPT, respectively.