Early high-dose chemotherapy with autologous peripheral blood stem cell support is the treatment of choice for patients with newly diagnosed multiple myeloma. Because of concerns of toxicity, this therapy is not usually administered to patients over the age of 65 years and is not covered by Medicare.
Controlled clinical studies have demonstrated that high-dose chemotherapy and autologous stem cell transplantation produces superior remission rates and significantly prolongs a patient’s duration of survival and time to cancer recurrence when compared to conventional chemotherapy. High-dose chemotherapy and autologous stem cell transplantation has become a standard of care for treatment of younger patients with multiple myeloma. Historically, older patients were not offered treatment with high-dose chemotherapy and autologous stem cell transplantation because of the increased side effects thought to occur in older patients. More recently, the use of stem cells collected from peripheral blood as opposed to bone marrow, the development of blood cell growth factors, improved antibiotic therapy, and other advancements in supportive care have markedly improved the safety of delivering high-dose chemotherapy. Several cancer centers around the world have begun offering this treatment to selected patients up to 70-75 years of age.
In order to evaluate the safety of delivering high-dose chemotherapy in older patients with multiple myeloma, investigators at the University of Arkansas performed a comparison between 49 patients with multiple myeloma over age 65 and 49 similar patients under the age of 65. Planned treatment consisted of 2 transplants utilizing Alkeran® (melphalan)-based high-dose chemotherapy supported by peripheral blood stem cell and a white blood cell growth factor (Neupogen® [filgrastim]). Seventy-six percent of the younger and 65% of the older patients were able to complete both transplants. After high-dose chemotherapy administration there was no difference between older and younger patients in the time to bone marrow recovery or other side effects. Two percent of younger patients died as a complication of therapy compared to 8% of older patients. All mortality was experienced during the first transplant and no mortality was experienced during the second transplant.
Physicians in the Southwest Oncology Study Group have also evaluated treatment in patients with multiple myeloma greater than age 65. The results of their evaluation were presented at the American Society of Hematology meeting in New Orleans.
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Following conventional chemotherapy, the average survival of patients less than age 65 was 37 months compared to 28 months for patients age 65-74. This analysis shows that age is an important factor for survival after conventional treatment. In contrast, cancer-free and overall survivals were identical for patients less than 65 or over 65 following autologous stem cell transplantation. In the low-risk group, patients under 65 and over 65 had an average survival of 4.5 years. In the intermediate risk group, patients under 65 and over 65 had an average survival of 2.5 years. For bad risk patients, the average survival was 1.2 years regardless of age.
High-dose chemotherapy and autologous stem cell transplantation can be safely administered to older patients. Moreover, recent evaluations suggest that age is not a significant factor for outcome. Medicare should consider funding of this treatment for older individuals with multiple myeloma. (Blood, Vol 94, No 10, Suppl 1, Abstract 3157, pp 715a, 1999)
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