Multiple myeloma is a cancer originating in plasma cells, a type of white blood cell found in bone marrow. These abnormal cells can accumulate, crowding out healthy blood cells and producing proteins that can damage organs. A prognosis describes the likely course and outcome of a disease. A patient’s age at diagnosis is a significant factor in determining this trajectory.
General Prognostic Factors in Multiple Myeloma
The Revised International Staging System (R-ISS) is the most widely used framework to assess prognosis for multiple myeloma. This system categorizes the disease into three stages (I, II, or III), providing a comprehensive view of its aggressiveness. R-ISS integrates several key biological markers to assign a stage.
R-ISS components include blood levels of beta-2 microglobulin and albumin. Higher beta-2 microglobulin, a protein on white blood cells, indicates greater disease activity. Lower albumin, a liver-produced protein, suggests a less favorable prognosis.
Beyond blood markers, the R-ISS also incorporates lactate dehydrogenase (LDH) levels and high-risk genetic mutations, known as cytogenetics. Elevated LDH often signals a higher tumor burden and a less favorable outcome. High-risk cytogenetic abnormalities, such as deletions on chromosome 17 (del(17p)) or translocations involving chromosomes 4 and 14 (t(4;14)) or 14 and 16 (t(14;16)), indicate a more aggressive form of the disease. These factors help stratify patients and guide treatment decisions.
Survival Rates by Age Group
The 5-year relative survival rate compares the survival of people with a specific cancer to the survival of people in the general population who do not have that cancer, matched for age, sex, and race. For example, a 5-year relative survival rate of 60% means individuals with cancer are 60% as likely as those without to live for at least five years after diagnosis.
Recent data from the Surveillance, Epidemiology, and End Results (SEER) database indicate an overall 5-year relative survival rate for distant multiple myeloma, which is the most common presentation, of around 62% for diagnoses made between 2015 and 2021. Survival rates for multiple myeloma vary significantly with age, with younger patients generally having higher rates.
Historical data from 2003-2007 showed 5-year relative survival rates over 70% for patients aged 15-44 years, with improvements across all age groups over time. Survival generally shows a stepwise reduction with each added decade of life. Patients under 50 often experience the most favorable outcomes, reflecting greater physiological reserve and eligibility for more aggressive treatments.
Survival rates decrease for individuals in the 50-64 age bracket, though they still generally fare better than older cohorts. Patients aged 65-74, who represent a significant portion of newly diagnosed cases, have lower 5-year relative survival rates than younger groups. The oldest patients, those 75 and older, generally face the lowest survival rates, with early mortality being most common in those aged 70 or older. This decline reflects disease biology, co-existing health conditions, and treatment tolerability, which becomes more pronounced with advanced age.
Factors Influencing Age-Based Prognosis
Differences in survival rates across age groups stem from several interconnected factors beyond chronological age. One influence is comorbidities, other health conditions existing alongside multiple myeloma. Older adults often have chronic diseases like heart disease, diabetes, or kidney problems, which can complicate treatment selection and increase the risk of adverse events. These co-existing conditions can limit the types and intensity of treatments a patient can safely receive, potentially affecting their long-term outcome.
Another factor is performance status and frailty. Performance status reflects a patient’s general well-being and ability to perform daily activities. Older patients, particularly those who are frail, may have less physical reserve and a diminished capacity to tolerate aggressive therapies. Frailty, a decline in physiological systems, increases vulnerability to cancer and its treatment. Tools like the International Myeloma Working Group (IMWG) frailty score, which considers age, comorbidities, and functional status, help identify patients at higher risk of toxicity and poorer survival.
Historically, age played a substantial role in determining eligibility for intensive procedures, such as autologous stem cell transplant (ASCT). ASCT involves high-dose chemotherapy followed by the infusion of a patient’s own previously collected stem cells. While ASCT remains a standard of care, older individuals were often excluded from trials due to concerns about toxicity. However, chronological age is no longer the sole determinant. A comprehensive assessment of overall health, including comorbidities and performance status, is paramount for ASCT consideration, with many centers considering patients up to 70-75 years of age if they are otherwise fit.
Adapting Treatment Strategies for Different Ages
Treatment strategies for multiple myeloma are carefully adapted to a patient’s age, overall health, and ability to tolerate therapy. For younger, fitter patients, the standard approach often involves intensive induction chemotherapy regimens, typically a combination of three drugs, followed by an autologous stem cell transplant. This aggressive strategy aims to achieve deep and durable responses, improving both progression-free and overall survival. After transplant, maintenance therapy, often with drugs like lenalidomide, is commonly used to prolong remission.
For older or less fit patients, treatment focuses on maximizing efficacy while minimizing side effects and maintaining quality of life. Less intensive chemotherapy regimens are frequently employed, often involving two or three drugs with potential dose adjustments to enhance tolerability. These regimens might include combinations of proteasome inhibitors, immunomodulatory drugs, and steroids, which are the backbone of myeloma treatment.
The development of novel targeted therapies and immunotherapies has significantly expanded options for older adults. Drugs such as anti-CD38 monoclonal antibodies (e.g., daratumumab) and newer bispecific antibodies are increasingly integrated into treatment plans, offering effective options with manageable toxicity profiles for this population. Continuous, low-intensity treatment is often preferred over fixed-duration therapy in older patients, demonstrating improved progression-free and overall survival. Ongoing research continues to explore new drugs and strategies to improve outcomes for all patients, regardless of age.