Should frailty and functional status be assessed before treatment is started? how is it assessed?

Should frailty and functional status be assessed before treatment is started?

How is it assessed?

How will results guide treatment?

I really think frailty and functional status should be measured both at the start of treatment and throughout the treatment trajectory and potentially help guide decisions around treatment.

So at the beginning of diagnosis, when we're really assessing a patient, we want to know what does their functional status and frailty status look like? And that's a combination of different things. It's not just, you know, a good ECOG performance status. We know that that doesn't capture everything. We want to look at their comorbidities. We want to look at their activities of daily living. Are they able to dress independently? Are they able to move around independently? Are they able to take care of themselves?

And we also want to take a look at activities of independently living. Are they able to take care of their own medications, their own finances?

And some of these concepts have been incorporated in tools. So, for example, the international Myeloma Working Group Frailty tool captures all of it. And we know that that tool is actually quite powerful because it can predict treatment toxicity and it can even predict efficacy.

So I think that's an important one. We should really incorporate this in initially at diagnosis. And I would suggest that we do the IMWG or some form of frailty index and that ECOG performance status on its own is likely not enough anymore.

The second part is that as we showed in our ASH abstract in 2022, this year, is that you can't just measure it at one time point. You need to go back and remeasure it, and in fact remeasuring frailty and functional status one changes from what it may be at the time of diagnosis, and to that it's in fact actually better be able to potentially predict how you're going to do than something that was measured at the time of baseline.

One of the first things frailty assessment does is it points to things that we may have entirely missed out. So one of the abstracts that we're presenting this year, in fact, shows that even patients who had quote unquote good ECOG performance status actually had these deficits in important domains that we may not realize until we actually do those assessments. So when you're aware of that, that may affect things.

So to give you an example for cognition, you know, we sometimes don't know what our patients' baseline cognitive status is, but once you start to potentially do it as part of an assessment, you realize, I need to worry about this. I need to worry about it for medication adherence. So maybe I need to provide my patient with better support so they actually take the medication.

And the second is something easy, like dexamethasone, which is incorporated in so many of the myeloma regimens. If you note that there's some cognitive impairment to start off with, you'll need to be much more careful with your steroid dosing. So that's two practical examples of how frailty assessment and again, cognitive assessment can really impact decision making.

Frailty and fitness assessments are absolutely key. And unfortunately, a lot of things that we do regarding frailty and fitness are not as rigorous as they ought to be. We tend to use in the clinical setting what a professor of mine used to say, the eye of the tiger, the patient has the eye of the tiger, and not remembering back to the Rocky movies.

But in reality, there's a number of simple frailty assessment scores and things like the four-minute walk test and having the patient walk around and tell you about what their daily activities are. And we can use some of these regimented approaches to figure out should we give someone full dose treatment, maybe dose reductions, or even instead of giving them three drugs, give them two drugs. So there are these assessments. We do use them, but they really bring us back to the core. That age is not a number. We all have those 80-year-old patients who are running marathons and why should they get any less therapy simply because they're 80 years old.

Yeah, those are hard. So especially in a clinic, and you know we have all these tools. So the IMWG actually has a frailty score, which is based on some geriatric studies that were done, and there's some great tools out there. But the problem is that in clinic we can't do those in real time. It's really hard when we're seeing multiple patients.

And so really for us, we end up for my patients who are frail, who are, let's say, going to still go to, you know, transplant potentially because it's from their myeloma or we want to get them to CAR-T because even some of our older frail patients can get through CAR-T. And what we do is we have our multidisciplinary team see these patients.

So we have them see nutrition, we have them see our, you know, geriatrics team. We have a special PharmD group that will look at all their medications to make sure that we're optimizing those if they have other comorbidities, for instance, cardiac, heart, lung or kidney disease. We have them see those doctors to make sure everything is optimized before we go on to any type of high-risk therapy, which usually is anything that requires hospitalization, mostly.

And again, I think that multidisciplinary team effort is so important because as a myeloma doctor, I would love to do all these things myself, but I just can't. And so we really need those other doctors to help us with anyone that looks frail in the sense that they have other major comorbidities or they're just slower or they are older.

So even my older patients who look great also have them see some of our specialists just to make sure we're not missing something. Response to treatment is really important because our goal in the end, for no matter what patient is coming to see me, I want to get that myeloma to the lowest level, but also make sure that the quality of life is preserved.

So if someone is really frail, I'm going to decrease the treatment levels. If they're doing really, really well, I'll decrease the dosing or maybe even decrease to one drug as a maintenance really quickly because they've just had such a great response so that their quality of life is much more preserved versus if I have someone who is frail and their disease isn't coming down, I might decrease the doses if they're having toxicity, but I might add a different drug to it so that I can really knock that myeloma down to the best level so that they can still get a good quantity of life with that better quality of life to decrease that toxicity versus patients who are really fit.

You know, why that's so important is that it opens up so many more options that I can treat a little bit more aggressively that won't affect their quality of life. And if it's not working, if they're not responding, I can switch to something else that I don't have to worry about the toxicity and I can really focus on knocking that myeloma down really, you know, to 0 as close as possible.