How is myeloma treatment personalized for varying levels of fitness and frailty?

[Music] how is myeloma treatment personalized for varying levels of fitness and frailty all of the medications that we use for multiple myeloma are really adjusted for individuals fitness the most classic example is dexamethasone the standard dose of dexamethasone is 40 milligrams once weekly however for patients who are not particularly fit their risk of complications from dexamethasone weakness in the thighs high blood sugar accelerated bone loss and infection are magnified these patients really should not receive full doses and should be attenuated to lower doses instead of 10 pills once a week five pills or two pills once a week until we know what the side effects are and then adjustments can be made the same is true with velcade people who are fit appear to be less likely to develop diarrhea low platelet counts and of course peripheral neuropathy and so for patients who are very frail it's my practice to actually reduce the velcade dose by 50 until i'm certain it becomes tolerable and then we can bring the doses into the mainstream finally there are medications that we use for multiple myeloma that can adversely affect normal blood counts patients who are fit appear to have less impact on their normal blood counts than frail patients and so it is also my practice to reduce the dose of those myeloma drugs that affect the normal blood counts and reduce those to be sure we don't get an ex accelerated reaction with unusually low blood counts and so it is important to take into account the patient's overall clinical performance are they walking are they in a wheelchair what's their daily activity level before you can really intelligently plan treatment for them as we gain insights into the biology of the disease we can actually tailor it based on patients risk factors there are other aspects that we take into account does the patient have kidney impairment how disabled has the patient become with the myeloma that would dictate the relative intensity determining which patients are safe candidates for autologous stem cell transplantation are these patients fit and are capable of walking a mile a day or are these patients wheelchair bound and disabled related to pain all of these are taken into consideration in arriving at an appropriate combination treatment for the management of their multiple myeloma so there's both clinical factors as well as biologic factors that are taken into account as we determine what would be an appropriate individualized management strategy is fitness status incorporated into the nccn guidelines the nccn guidelines fit and unfit have not as yet been incorporated but dr shaji kumar of mayo clinic is the head of the myeloma section of nccn and is planning to incorporate that down the line in msmart we do talk about different modifications uh looking at an emphasis on oral combinations for less fit patients or immobilized patients so they don't have to keep coming to the clinic for injections and gentler regimens for the frail patients so that's a relatively new component of the m smart guidelines but we have incorporated them personalized medicine and although it sounds sort of far-fetched actually doctors have been doing it for years and so you know we clearly recognize that there's one approach for younger fit patients and you know you push the therapeutic envelope in those patients they survive better then there's the elderly fit it's clearly a different group there are different considerations if you present your fit at 68 you know how far do you want to tolerate the side effects of treatment when you have comorbidities you're forced to reduce the intensity of your treatment and so you can choose for those patients and then there's the very frail patients where you have to be very careful up front and it's all about being gentle allowing them some chance to recover and getting the best outcome that you can so we do personalize the therapeutic [Music] decisions