IMS 2025 | Considering frailty in myeloma treatment decisions: advice for clinicians

So I’m going to be a bit contrarian in terms of this question. So frailty is really an important clinical feature. If somebody is frail, then you clearly shouldn’t take the most aggressive therapy you have, try and blow their disease out of the water to get better outcomes. So what I would contend though is in the clinic, we’ve been paying lots of attention to frailty without really having scores and adjusting therapy appropriately. So I tend to treat people who are fitter with four drug regimens. So if I see somebody who is not perhaps as well as somebody else, then I’ll treat them with three drugs and leave the bortezomib out, for instance. If they’re frailer than that, maybe I’ll just treat them with two drugs, see how they go for a few cycles. If they improve by then, then I’ll add the other drugs back in. But it’s not like a black and white score that you do in the clinic. This is good clinical medicine that should always take account of the patient’s clinical condition, their performance status, and comorbidities. And the treatments are so effective now and we know exactly how they behave. It is much easier to adjust the treatment in the clinic to make sure everybody gets the best outcome. Just because you’re frail to start with doesn’t mean you’re going to be frail after three months of treatment, and those patients deserve the four drugs rather than a two drug regimen. So I think that’s the way it’s going to go in the clinic, but in the background, people are going to start to make scores of frailty that can be applied. And if you’re going to run clinical trials, you need something specific. You can’t just eyeball it. But in the clinic, I think the clinical approach is better.

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