ABSTRACT
This chapter will review the treatment options available today for the elderly patient with mutliple myeloma. Nearly three decades of clinical trials exploring conventional-dose chemotherapy have resulted in no appreciable improvement in the outcomes of patients with myeloma. The past 10 years, however, have seen the development of new strategies and early confirmation of their benefits. These will be the primary focus of this chapter and include (i) the role of high-dose therapy with autologous hematopoietic stem cell transplantation (HSCT), (ii) demonstration of a graft-versus-myeloma effect, (iii) adjuvant therapy of bone disease, and (iv) activity of thalidomide. Each of these developments represents substantial improvements in survival, disease control, and/or quality of life of patients with myeloma. In the last section, we shall briefly discuss how recent knowledge gained in our understanding of the biology of the disease is shaping the development of new therapies. An extensive discussion on the biology, clinical features of the disease, and conventional therapy of this disease is outside the scope of this chapter. The reader is referred to several excellent recent reviews on the subject.1-3
Multiple myeloma in the elderly does not appear to have distinct biological or clinical characteristics compared with those of younger patients. Several studies (reviewed by Ballaster et al4) have indicated that the outcomes of elderly patients with myeloma are similar to those of younger individuals, provided they receive comparable therapy. The very old myeloma patient, however, may be at higher risk primarily from the occurrence of comorbid conditions. In a recent review of 130 patients over the age of 75, only patients over 85 were found to have a poor prognosis. The diagnosis of myeloma is more often delayed in older patients. This appears to be related to the fact that bone pain is initially neglected or misinterpreted in older patients, since this is a common complaint. The study also found that infections are more common at presentation in the elderly population.5
