Morphometrics predicts overall survival in patients with multiple myeloma spine metastasis: A retrospective cohort study

Background: Treatment strategies for spinal metastases for myeloma range from conservative measures (radiation and chemotherapy) to invasive (surgical). Identifying better predictors of overall survival (OS) would help in surgical decision making. Analytic morphometrics has been shown to predict survival in oncologic patients, and our study evaluates whether morphometrics is predictive of survival in patients with multiple myeloma (MM) spinal metastases. Methods: For this observational retrospective cohort study, we identified 46 patients with MM spinal metastases who had undergone stereotactic body radiation therapy. OS was the primary outcome measure. Morphometric analysis of the psoas muscle was performed using computed tomography scans of the lumbar spine. Results: OS was statistically correlated with age ( Conclusions: Morphometric analysis successfully predicts long-term survival in patients with MM. More research is needed to validate these results and to see if these methodologies can be applied to other cancer histologies

Morphometrics predicts overall survival in patients with multiple myeloma spine metastasis: A retrospective cohort study

BACKGROUND: Treatment strategies for spinal metastases for myeloma range from conservative measures (radiation and chemotherapy) to invasive (surgical). Identifying better predictors of overall survival (OS) would help in surgical decision making. Analytic morphometrics has been shown to predict survival in oncologic patients, and our study evaluates whether morphometrics is predictive of survival in patients with multiple myeloma (MM) spinal metastases. METHODS: For this observational retrospective cohort study, we identified 46 patients with MM spinal metastases who had undergone stereotactic body radiation therapy. OS was the primary outcome measure. Morphometric analysis of the psoas muscle was performed using computed tomography scans of the lumbar spine. RESULTS: OS was statistically correlated with age (P = 0.025), tumor burden (P = 0.023), and number of levels radiated (P = 0.029), but not with gender. Patients in the lowest tertile of average psoas size had significantly shorter survival compared to the highest tertile, hazard ratio (HZ) 6.87 (95% CI = 1.65-28.5, P = 0.008). When calculating the psoas size to vertebral body ratio and correlating this measure to OS, the lowest tertile again had significantly shorter OS compared to the highest tertile, HZ 6.87 (95% CI = 1.57-29.89, P = 0.010); the middle tertile also showed significantly shorter OS compared to the highest tertile, HZ 5.07 (95% CI = 1.34-19.10, P = 0.016). Kaplan-Meier survival curves were used to visually illustrate the differences in survival between different tertiles (Log-rank test P = 0.006). CONCLUSIONS: Morphometric analysis successfully predicts long-term survival in patients with MM. More research is needed to validate these results and to see if these methodologies can be applied to other cancer histologies

Geriatric assessment in hematology scale predicts treatment tolerability in older patients diagnosed with hematological malignancies: The RETROGAH study

Chemotherapy; Geriatric assessment; ToxicityQuimioterapia; Evaluación geriátrica; ToxicidadQuimioteràpia; Avaluació geriàtrica; ToxicitatIntroduction The GAH (Geriatric Assessment in Hematology) scale is a psychometrically valid tool aimed at identifying older patients with hematological malignancies at higher risk of treatment-related toxicity. Our objective in this study was to determine the weights for each dimension of the GAH scale and the cut-off point to reliably predict treatment tolerability in this population, estimated by a weighted receiver operating characteristic (ROC) analysis and quantified by the area under the curve (AUC). Material and Methods The RETROGAH was a retrospective cohort study including 126 patients who had previously participated in the GAH study. Patients were ≥ 65 years old with newly diagnosed myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML), multiple myeloma (MM), or chronic lymphoid leukemia (CLL) and treated with standard front-line therapy within three months after having completed the GAH scale. Results The optimal cut-off value of the GAH total score to discriminate patients at higher risk of treatment toxicity was 42, with 68.5% sensitivity and 55.8% specificity. Using this value, 66.1% of patients evaluated were found to develop some type of toxicity. The AUC was 0.6259 (95% CI: 0.512–0.739; p = 0.035). Discussion The GAH scale not only would enable clinicians to individualize therapy based on individual risk of toxicity but also discriminate patients that will benefit most from intensive treatments from those requiring an adapted approach. While futures studies in clinical practice may improve the model and overcome its limitations, the GAH scale should not be used alone when making treatment decisions.This study was supported by Celgene España S.L

Guidelines for screening and management of late and long-term consequences of myeloma and its treatment

A growing population of long-term survivors of myeloma is now accumulating the ‘late effects’ not only of myeloma itself, but also of several lines of treatment given throughout the course of the disease. It is thus important to recognise the cumulative burden of the disease and treatment-related toxicity in both the stable and active phases of myeloma, some of which is unlikely to be detected by routine monitoring. We summarise here the evidence for the key late effects in long-term survivors of myeloma, including physical and psychosocial consequences (in Parts 1 and 2 respectively), and recommend the use of late-effects screening protocols in detection and intervention. The early recognition of late effects and effective management strategies should lead to an improvement in the management of myeloma patients, although evidence in this area is currently limited and further research is warranted

Pretransplantation Assessments and Symptom Profiles: Predicting Transplantation-Related Toxicity and Improving Patient-Centered Outcomes

With the advent of reduced-intensity conditioning regimens and improvements in supportive care, hematopoietic cell transplantation (HCT) has become increasingly available to older adults and medically vulnerable populations with hematologic diseases. However, adverse outcomes including long-term treatment-related distress, disability (frailty), and death remain important concerns in this population. In other areas of oncology, comprehensive geriatric assessments have been used to stratify patients for treatment-related risk, and patient-reported outcomes (PROs) have helped in understanding treatment-related toxicity from a patient perspective. However, these powerful tools have not yet become widely used in HCT. Here, we review the theories and available data that support the development of pretreatment functional assessments and longitudinal PRO sampling in HCT. We discuss the potential for these techniques to improve transplantation outcomes through risk stratification, interventional studies, and predictive models that incorporate genetic and biomarker data. Predicting and understanding long-term transplantation-related toxicity through functional assessments and PROs will be critical to calculating the risk/benefit ratio of aggressive therapies in older patient populations, and we contend that functional assessments and PRO sampling should become standard parts of the routine evaluation of HCT patients

Risk and Response-Adapted Treatment in Multiple Myeloma

Myeloma therapeutic strategies have been adapted to patients' age and comorbidities for a long time. However, although cytogenetics and clinical presentations (plasmablastic cytology; extramedullary disease) are major prognostic factors, until recently, all patients received the same treatment whatever their initial risk. No strong evidence allows us to use a personalized treatment according to one cytogenetic abnormality in newly diagnosed myeloma. Retrospective studies showed a benefit of a double autologous transplant in high-risk cytogenetics according to the International Myeloma Working Group definition (t(4;14), t(14;16) or del(17p)). Moreover, this definition has to be updated since other independent abnormalities, namely gain 1q, del(1p32), and trisomies 5 or 21, as well as TP53 mutations, are also prognostic. Another very strong predictive tool is the response to treatment assessed by the evaluation of minimal residual disease (MRD). We are convinced that the time has come to use it to adapt the strategy to a dynamic risk. Many trials are ongoing to answer many questions: when and how should we adapt the therapy, its intensity and duration. Nevertheless, we also have to take into account the clinical outcome for one patient, especially adverse events affecting his or her quality of life and his or her preferences for continuous/fixed duration treatment

Tailored approach of the older person with a haematological malignancy

A significant increase has been seen in the number of older patients with cancer due to population ageing. Ageing however is a highly individualized and very heterogeneous process with a broad spectrum ranging from older persons who are functionally independent to those who are at high risk of functional decline and mortality and all the others in between. Fit older patients should logically receive the same treatment as their younger counterparts. The main problem however is the group of frail patients at increased risk for treatment complications. The main aim of this doctoral thesis was to explore whether in older patients with haematological malignancies a geriatric approach, and in particular a comprehensive geriatric assessment (CGA), might be worthwhile in the selection of patients with a geriatric profile, in the detection of geriatric syndromes and in the prediction of patient outcomes. In this thesis, we demonstrated that, also in patients with a haematological malignancy, a CGA can identify previously unknown geriatric problems in an individual. Through nutritional screening a large majority of patients was identified with potential nutritional problems. Given the negative impact of malnutrition on an anticancer treatment, regular follow-up and implementation of specific interventions, in collaboration with a dietician, are essential, even though efficacy of these interventions has not yet been adequately proven. Moreover, geriatric evaluation in this thesis has clearly proven that chemotherapy, and inherent use of supportive medication, leads to polypharmacy and frequent changes in medication regimen. Because of this, more than half of the patients are no longer able to manage their medication independently. As most older patients are living alone or are taken care of by a partner of the same age, their current care pathway should include a structured and repeated evaluation of functional autonomy with regard to medication management. This thesis did focus not only on the detection of geriatric syndromes, but also on a correct selection of patients with a geriatric profile, as the administration of a CGA is time and staff-consuming. Therefore a two-step approach is proposed with the use of a screening tool to identify those patients that subsequently would benefit most from a CGA. During the conduct of our study we tested the performance of two different screening tools. G8 (with a cut-off of ≤14) could be validated for use in older patients with haematological malignancies. In contrast with G8, an 8-item questionnaire, hand grip strength is a performance-based measure and therefore a more objective reproduction of a patient’s functional reserves. In contrast with healthy individuals, we found that hand grip strength was reduced in patients with haematological malignancies, even before onset of treatment. Using a Martin vigorimeter, we also determined minimum values for hand grip strength in men and women. Below these values, all patients should be referred for further geriatric evaluation. This doctoral thesis should be considered a first onset in the development of a multidisciplinary approach in older patients with haematological malignancies. Further research should focus for one thing on interventions that, before start of treatment, can optimize the functional reserves of a frail patient, and for another thing on new treatment modalities incorporating the results of the CGA. Integration of the results of both lines of investigation should eventually lead to a treatment plan tailored to the individual patient

Multicomponent frailty assessment tools for older people with psychiatric disorders: a systematic review

Objective: To review evidence evaluating the use of multi-component frailty assessment tools in assessing frailty in older adults with psychiatric disorders. Methods: A systematic literature review was conducted to identify all multi-component frailty assessment tools (i.e. a tool that assesses ≥2 indicators of frailty). The items of each frailty assessment tool were compared to DSM-5 diagnostic criteria for psychiatric disorders to assess construct overlap. Studies conducted in community, inpatient and outpatient clinical settings were considered for inclusion. Participants: Adults aged ≥60 years old. Results: 5,639 studies in total were identified following the removal of duplicates; 97 of which were included for review. Of the 48 multi-component frailty assessment tools identified, no tool had been developed for, or validated in, older adult populations with psychiatric disorder. 24/48 frailty assessment tools contained a psychological assessment domain, with 18/48 tools using presence of depressed mood and/or anxiety as a frailty indicator. Common areas of construct overlap in frailty assessment tools and DSM-5 diagnostic criteria included weight loss (29/48) and fatigue (21/48). Conclusions: Significant construct overlap exists between the indicators of frailty as conceptualised in existing frailty assessment tools and DSM-5 diagnostic criteria for common psychiatric disorders, including Major Depressive Episode and Generalised Anxiety Disorder, which has the potential to confound frailty assessment results. Further research is necessary to establish a reliable and valid tool to assess frailty in this population

Host-related factors and cancer: Malnutrition and non-Hodgkin lymphoma

Assessment of host-related factors is a crucial aspect in the comprehensive management of cancer patients. A distinct nutritional disturbance linked to cancer has been recognized to be associated with negative outcomes. However, compared to solid tumors, only a limited number of studies have looked specifically at nutritional issues in the field of lymphoma. The aim of this review is to integrate the current knowledge on interactions between malnutrition and lymphoma and address most relevant and pertinent questions. We first provide a literature review on the mutual biological relationship between malnutrition and lymphoma. Next, we explore the overlap between malnutrition, sarcopenia, cachexia and frailty in lymphoma studies. In addition, we summarize the clinical assessment scales used to measure malnutrition in lymphoma subjects. Furthermore, we address the problem of nutritional interventions aimed at patients who are candidates for treatment for lymphoma. Malnutrition can arise as a consequence of lymphoma disease and can in turn promote lymphomagenesis, negatively affect the response to therapy and favor adverse event to treatment. There is increasing evidence that malnutrition, sarcopenia and cachexia in lymphoma are intimately inter-related and are a hallmark of frailty. A variety of different tools are recorded with the apparent ability to describe nutritional status and to impact prognosis in lymphoma patients. Finally, a network of prognostic host- and disease-related factors is proposed where malnutrition can interact with each other in complex ways