Management of the Older Patient with Multiple Myeloma

More than 50% of patients with multiple myeloma are over the age of 60 years at the time of presentation. The presenting features in the elderly are the same as for younger patients, with bone lesions and pathological fractures, hypercalcaemia, anaemia and renal impairment. Some patients are asymptomatic with a paraprotein found incidentally. Fit patients up to the age of 70 years without cardiovascular or significant renal disease may be managed in the same way as younger patients by firstly having their tumour load reduced with combination IV chemotherapy, followed by high‐dose chemotherapy with peripheral blood stem cell rescue. In younger patients this aggressive approach has been shown to afford a survival advantage of approximately 18 months. Patients of more advanced age or with significant co‐morbidities may achieve a good response with judicious administration of oral chemotherapy, commonly melphalan and prednisolone. With dose adjustments to reduce toxicities patients can have durable disease responses and relief of symptoms even in the very elderly. The median survival without high‐dose chemotherapy is 3 to 5 years. This prognosis is not age‐specific, but agerelated co‐morbidities may limit treatment options and hence affect the prognosis adversely. Some patients have indolent disease with a superior prognosis, requiring treatment only with progression and development of symptoms. Prophylaxis with bisphosphonates has been shown to reduce the incidence of fractures and radiotherapy can afford excellent palliation. The introduction of thalidomide to routine care has given a further palliative treatment, with a third of patients refractory to chemotherapy responding. Clinical studies addressing the use of thalidomide earlier in treatment are being undertaken. Dose reduction is often required in older patients because of increased somnolence and constipation. Withdrawal may be required because of neurotoxicity. Newer agents with similar properties to thalidomide but with fewer toxicities are eagerly awaited.