How is frailty score determined?

What is the Revised Myeloma Comorbidity or RMCI? The Revised Myeloma Comorbidity Index was developed initially in Germany by Professor Engelhardt. And this is a score in which we use a patient's age along with their performance status, something known as Karnofsky Performance Status, their kidney function, and also their lung function. And together, along with the frailty phenotype that I described previously from Freed, the patients are then classified based on how they score on each of those individual measures. They receive an additive score, and that score is then used to categorize them into three categories, which is fit, intermediate fit, and also frail. Is the frailty score used for everyone? Frailty of a patient may change over time. Are these scores reevaluated? At present, the recommendations from many large societies, primarily in Europe, has been that we use or incorporate frailty indices into all adult patients with myeloma who are about to start a myeloma therapy. In reality, what is happening is that the uptake of frailty indices has been a little bit slower. And so right now, the most place, the place where you'll see this often used is in the research setting. So if I'm in my clinical practice, I generally would use the Revised Myeloma Comorbidity Index or the International Myeloma Working Group frailty score, which is the most commonly used. And we can talk a little bit about what that is. And I use that on all of my patients with newly diagnosed multiple myeloma. And then I tend to track that over time. So I want to see, as these patients go through their treatments, how does their frailty score or frailty index actually change? Because then that tells me or gives me an idea that with this patient's treatment, they may be tolerating it well or they may be tolerating it poorly. And they may be an indication that I actually need to make some changes to their therapies. What is the International Myeloma Working Group or IMWG frailty score? In 2015, Professor Perlumbo and colleagues actually published about the International Myeloma Working Group's frailty score. This score is similar to the RMCI, but it includes age, the comorbidities, so whether or not a patient has additional medical conditions. And this is measured by something known as the Charleston Comorbidity Index. And then we also think about a patient's functional status. And as a geriatrician, the way that we define functional status is slightly different as to how people with traditionally in oncology have described this. And so functional status is really taught about, you really think about it as instrumental activities of daily living as well as activities of daily living. And so I tell people all the time when you think about activities of daily living, these are the things that you need just to function every day. So these are the things like getting up, getting bathed, getting showered, getting your clothes on. These are considered your activities of daily living. In terms of the instrumental activities of daily living, this is what you need to exist in a community. Or I say for a university level student, this is what they need to exist on a day to day basis. So they need to be able to manage their finances to some certain degree, manage medications if they have any, and then arrange transportation for themselves and do other higher level chores which would allow them to function independently outside of their home. So when we use the IMWG frilty score, we add all of those things together, we get a number and that really classifies patients as to whether or not they are fit, intermediate fit or frail. How do the scores from the IMWG and RMCI compare? So in terms of the comparison between the IMWG and the RMCI, as of 2021, we still do not know whether or not there's an optimal tool for measuring frilty or for assessing these patients. So despite some analyses that may show that one tool may have a little bit better, be a bit better in terms of predicting who's going to do worse with treatment or who's going to be at risk for toxicity, we really don't know that answer. So generally I suggest to people when they're thinking about which score they should use, they should really choose the score they feel most comfortable with. Usually people gravitate towards the IMWG because it has fewer measures in it and the measures that they have can be easily performed in the office. If you could imagine most patients when they come in, you know their age, you know what their comorbidities are and you can easily ask about their functional status. But then if you go a step further with the RMCI, you need also to incorporate measures of lung function, kidney function, and then the freed frilty phenotype, which is not always easy to measure in a busy clinical practice. So most people tend to gravitate towards the IMWG frilty score in clinical practice. When is the RMCI score mostly used? In clinical trial settings, there's actually, I would say the setting where this is, the RMCI is mostly used is probably in Europe. The developer of the score, Dr. Engelhardt, she has really published on this and their use of this in things like tumor boards to help inform decisions. They use the RMCI in clinical trial settings also when they're designing studies to think about whether or not you want to classify a patient according to their fitness status to assign therapy. But then similarly, the IMWG score is also being used in clinical trial settings when you think about how to assign various myeloma treatments. Should a patient get multiple scores over time? You really get a great point where this idea that fitness or frilty is dynamic. And so as a patient comes in and they're newly diagnosed, the recommendations, and these are all recommendations based on consensus, expert opinion, not tested in a prospective or a randomized fashion. But recommendations would be to calculate what that patient's score is at baseline. And then once you have that score, as you treat that patient, maybe every cycle, you want to recheck that score again because these things can change. And for a patient who might have been fit at the beginning, they may start to get toxicities or have additional comorbidities, lose function, and that may change their score and they then become intermediate fit or they can become frill from being fit. And so you want to know that because it has implications on how you may want to treat that patient if you want to offer any dose adjustments to that particular patient. So at present, the way that this is used in clinical settings and largely, you know, persons who are interested in aging, you know, geriatric oncology, geriatric hematology, we tend to repeat it every cycle of treatment and we tend to follow it prospectively just to see if patients are having any changes. How long does it take to calculate that score? In my clinical practice, these scores are readily available. The IMWG is the one that I use the most. This is an online calculator and you plug all of the numbers in and I can get a score in about three minutes or less as long as I have all of the measures there. Basically using drop down menus and clicks basically. So it doesn't add a lot of time to a provider. Again, these are things that are already being captured in the medical record. The only thing that I would say is not being captured routinely is the functional status measures, the IADLs and ADLs. But even so, you can get a good sense of what those are from a patient just by talking to So it really doesn't add additional time to the treatment visit or the office visit, the routine office visit.