Older patients diagnosed with multiple myeloma are not receiving appropriate chemotherapy, despite guidelines [Íîâîñòü äîáàâëåíà -
12.11.2007]
Chemotherapy and survival for patients with multiple myeloma findings from a large nationwide and population-based cohort.
Rohatgi N, Du XL, Coker AL, Moye LA, Wang M, Fang S.
Am J Clin Oncol 2007; 30: 540–48.
Chemotherapy for patients with multiple myeloma is just as effective in a real world setting as it has been shown to be in clinical trials, according to the first study to assess this issue, published in the American Journal of Clinical Oncology. However, as reported in previous studies, the older patients are when diagnosed, the more likely they are to miss out on this life-extending treatment. It is a well known phenomenon that elderly patients are underrepresented in clinical trials. For multiple myleoma, this skewed situation has led to uncertainty over whether the efficacy of treatments formally documented in younger patients is generalisable to older individuals in a community setting. To investigate whether the survival benefit of chemotherapy for multiple myleoma is maintained across all age ranges, and work out whether older patients actually receive the appropriate chemotherapy as recommended by treatment guidelines, Nidhi Rohatgi and colleagues from the MD Anderson Cancer Center and the University of Texas undertook a large population-based study.
Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, the group the researchers chose to study consisted of elderly patients (older than 65 years) who had been diagnosed with multiple myeloma between 1992 and 1999. The main objectives of the study were to determine what proportion of patients received chemotherapy as recommended; what factors were associated with not receiving this therapy; and whether chemotherapy was effective in prolonging survival among elderly patients outside the clinical trial settings.
A cohort of 4902 patients with late stage multiple myeloma was identified, for whom chemotherapy should have been universally recommended. Using Medicare claims records, the researchers then identified the patients who had received chemotherapy or radiotherapy and linked these findings to census data to ascertain socioeconomic status.
Dividing the group into those who had received chemotherapy and those that had not the researchers compared several variables. The distribution of patients who received chemotherapy was different from those who did not in terms of age, comorbidities, radiation therapy, year of diagnosis and geographic area, but there was no significant difference in terms of gender, race/ethnicity, and socioeconomic status.
Overall, 52.0% of the group had received chemotherapy during the course of their disease. The receipt of chemotherapy decreased substantially with age from 65.7% in patients 65 to 69 years to 34.3% in those older than 80 years. After adjusting for gender, ethnicity, comorbidity, radiation therapy, socioeconomic status, year of diagnosis, and geographic areas, patients who were 70 to 79 years were 41% less likely to receive chemotherapy than patients who were 65 to 69 years of age. The rate of receiving chemotherapy decreased slightly from high to low socioeconomic status, and increased significantly over time from 1992 to 1999.
Looking at overall survival, the researchers calculated a median survival time of 5.9 years for patients receiving chemotherapy and 1.6 years for those who did not, an effect that seemed to be cumulative with amount of chemotherapy received. Compared with patients who did not receive chemotherapy, those who received 1 to 5 cycles were 16% less likely to die of all-causes, whereas those who received 25 to 35 cycles were 53% less likely to die. This survival benefit was statistically significant in all strata of age, gender, race, comorbidity, and radiation therapy. “We found that receiving chemotherapy was associated with 35% survival advantage, and this survival benefit was significant across different age groups, ethnic groups, gender, and comorbidity scores. However, a large proportion of the elderly patients with stage II or III multiple myeloma did not receive chemotherapy and the receipt of chemotherapy decreased substantially with age,” say the authors.
Although numerous clinical trials have documented the efficacy of chemotherapy, Rohatgi and colleagues believe theirs is the first to evaluate the effectiveness of chemotherapy in elderly patients outside clinical trial setting, and they are worried by their findings: “Since chemotherapy was associated with increased survival rate in all age groups of the elderly patients with multiple myeloma, it is therefore concerning if age is still a barrier to the recommended therapy,” they conclude.
Chemotherapy and survival for patients with multiple myeloma findings from a large nationwide and population-based cohort.
Rohatgi N, Du XL, Coker AL, Moye LA, Wang M, Fang S.
Am J Clin Oncol 2007; 30: 540–48
