Geriatric Assessment in Older Adults with Multiple Myeloma

Introduction: Multiple myeloma (MM) is a disease of older adults, yet standard baseline assessments do not include assessment of physiologic age or frailty. In older adults with cancer, geriatric assessment (GA) predicts treatment toxicity and survival. In MM, frailty is associated with treatment discontinuation, toxicity and survival (Palumbo Blood 2015). Studies of patient preferences have shown that maintenance of independence in daily activities is a high priority in older adults with serious medical conditions (Fried NEJM2002) We sought to examine GA factors associated with 1) autologous stem cell transplant (ASCT) eligibility and 2) increased functional dependence over follow-up.

Methods: Patients (pts) with newly diagnosed MM aged 65 and older were enrolled in a prospective cohort study at 2 institutions. Pts underwent a brief, primarily self-administered geriatric assessment (GA) at baseline, 3- and 6-months of follow-up. GA included functional status (instrumental activities of daily living/IADLs), medications, cognition (Short Blessed Test), psychological state (Mental Health Inventory), the Timed Up and Go physical performance test (TUG) and the Charlson comorbidity index (CCI). Analyses were performed using SAS v9.4/Stata 14.1. Descriptive and inferential statistics were used to summarize and compare groups, as appropriate.

Results: 40 pts enrolled, with a median age of 69.5 (range 65-84). 77.5% were white, 12.5% black and 10% other/unknown. 62.5% were male. Median MD-rated Karnofsky performance status (KPS) was 80 (range 50-100). Geriatric syndromes were common, with 62.5% of patients reporting dependence in one or more IADLs, 47.5% with one or more comorbidities, 28.5% reported one or more falls in the prior 6 months and 10% screened positive for cognitive impairment. Median number of medications was 9 (range 1-23).

26 pts (65%) were felt to be ASCT candidates by the treating physician, who was blinded to the GA. Factors associated with MD-determined ASCT candidacy were: fewer comorbidities (mean CCI 0.6 vs. 1.9. p=0.0065), higher MD-rated KPS (71% MDKPS ≥80 vs 47%, p=0.021 ) and faster TUG (mean 11.9 seconds vs 15.8, p=0.013). While 26 were considered eligible, only 21 pts (52.5%) ultimately underwent ASCT [attrition due to pt preference (2), progression (1), failed mobilization (1) and unknown (1)]. Increasing age (OR 0.77/year, 95%CI 0.601-0.988) and IADL dependence (OR 0.043, 95% CI 0.004-0.464), but not KPS or comorbidities, were independently associated with decreased odds of actually undergoing ASCT.

We also examined factors associated with changes in functional status in the 36 patients who completed 6-month follow-up. 6 pts (16.7%) had a 2 point increase in dependence in IADLs. In a generalized linear model, undergoing ASCT and baseline comorbidities were independently associated with higher IADL scores at 6-months (p=0.036, p=0.033 respectively). All patients with an increase in IADL scores (increased functional dependence) had a change in treatment regimen due to toxicity. Age, International Staging System Stage, gender, deletion 17p and disease progression were not associated with increased functional dependence. Development of peripheral neuropathy was not associated with IADL dependence or falls. Conclusions: GA reveals that geriatric syndromes are common in older adults with multiple myeloma. GA may provide a framework to objectively define transplant eligibility. Increased functional dependence is associated with baseline comorbidities and undergoing ASCT. Further study is needed to examine the utility of GA in predicting treatment toxicity and survival.