IMWG Updates Guidelines for Myeloma Patients Ineligible for ASCT

The International Myeloma Working Group recently released a consensus statement updating recommendations for the management and treatment of patients with multiple myeloma who are not eligible for standard autologous stem-cell transplantation.

The statement includes recommendations that take into consideration the latest therapeutic advances and are meant to guide physicians in a careful screening of patients to identify the most appropriate approach for patients with multiple myeloma, both during general practice and clinical trials. The International Myeloma Working Group guidelines for the management of these patients were last updated in 2009.

“During the past decade, considerable progress had been made in defining new diagnostic parameters, prognostic markers, and treatment options, prompting the International Myeloma Working Group to present a major revision of the previous guidelines,” Antonio Palumbo, MD, chief of the myeloma unit at the University of Torino, Italy, told Cancer Network. “In particular, new drugs such as thalidomide, lenalidomide, and bortezomib have been tested in different combinations, as induction and maintenance therapy.”

The updated recommendations are based on a 2012 literature review conducted by the group. In cases where published information was insufficient for a recommendation, the group considered expert consensus for its guidelines. Palumbo recently discussed the updated consensus statement with Cancer Network, highlighting some of the most important new recommendations.

Myeloma patients ineligible for high-dose chemotherapy and autologous stem-cell transplantation are a highly heterogeneous population. When looking to identify patients fit for transplant, an age cut off of 65 years is no longer valid. Instead, the statement recommends that clinicians consider age, comorbidities, and a geriatric assessment in order to determine if a patient is fit or unfit for transplant.

“A careful initial assessment using the latest geriatric scores is crucial to appropriately identify patients and consequently provide them with tailored, effective therapies,” Palumbo said. “For instance, the Charlson Index, the Activities of Daily Living, and Instrumental Activities of Daily Living are simple and useful tools.”

In addition, drug doses should be adapted based on patients’ characteristics in order to avoid excessive toxicities that may lead to treatment discontinuation that could negatively affect survival or quality of life.

“Fit and very fit patients can be treated with full-dose therapies containing new drugs, and three-drug induction therapies or reduced-intensity autologous transplantation can be safely adopted,” Palumbo said.

However, unfit patients should receive less intensive approaches. In these patients, two-drug regimens or three-drug regimens with appropriate dose reductions are a sensible choice.

The consensus statement also makes several recommendations regarding the prompt management of treatment-related adverse events such as bone disease, infections, thromboembolism, or renal failure. According to Palumbo, prompt action in the treatment of these adverse events is a fundamental part of the clinical approach for physicians.

The authors of the guideline noted that some of the treatments recommended in the consensus statement are not approved by regulatory authorities and should only be considered as “reasonable treatment options.” The full statement can be found in the Journal of Clinical Oncology.