Published on July 25, 2019
Myeloma expert Dr. Tanya Wildes, from the Washington University School of Medicine,gives an expert perspective on how to approach care for the older or aging multiple myeloma patient population. She identifies age-associated risk factors and ways to reduce treatment toxicities. Dr. Wildes also shares how patients can advocate for themselves, take control of their health and maintain optimum functionality. Watch now to learn her expert view.
Transcript | Myeloma Expert Shares New Insights on Effective Care for Aging Patients
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You deal with geriatric issues, which often go along with older people typically with myeloma. So what can people do? Not just be terrified whether there's this high?risk label, but is it a matter of more working with their physician on their whole situation? Not just what myeloma drugs they should have?
Yes. There are a number of approaches we can use in this situation, first focusing on the decision-making aspect of things. One of the important factors will be to determine if an older adult is at greater risk for toxicity of therapy, side effects based on these aging-associated vulnerabilities.
For example, how we use bortezomib (Velcade) can significantly impact the adverse events it causes. For example, when administered twice a week there is a much higher rate of peripheral neuropathy than if it's administered subcutaneously and once a week. And when big studies have looked at the amount of dose of—accumulated dose of bortezomib that can be administered, basically there's lower toxicity and patients can get treated with bortezomib longer when it's given subcutaneously and once a week rather than twice a week.
This is particularly important because this peripheral neuropathy can interfere with daily activities.
Yeah, yeah. You've lived it, I'm sure. You know people who have lived that kind of experience. And what clinicians forget when we look at the grading of toxicities is that even a grade 2 peripheral neuropathy by definition is interfering with the instrument al activities of daily living. Now, that's how a geriatrician categorizes the activities one performs to stay independent in the community. That's the ability to handle finances, do transportation, prepare one's own meals, all those just day?to?day things.
And so to an oncologist two neuropathy doesn't sound that bad, but to a patient, grade 2 neuropathy interfering with their daily activities is a really big deal, and it can increase risk of falls and that sort of thing.
So in answer to your question one of the first steps is for the oncologist to be aware of how the patient's underlying aging-associated vulnerabilities may increase their risk for toxicities that have these downstream effects. As far as what the patient can do and their family, it may take some advocating to look at their decision-making through an aging?associated focus. As I mentioned, toxicities that may not reach the bar that, say, in a clinical trial is considered severe, grade two neuropathy can still be very, very impactful on a patient's quality of life and may not be in line with their goals and preferences for their treatment.
Some of the other things a patient can do to really advocate for themselves with an eye towards these aging-associated vulnerabilities, medications are just a massive part of the health of an older patient. In the geriatrics literature taking more than five medications is considered polypharmacy. That's the tip of the iceberg for our patients. They walk in the door and we give—if they were on zero medicines when we started, by the time they walk out with their oncologist they're on at least five more, whether that's lenalidomide (Revlimid), dexamethasone (Decadron), adding in prevention for blood clots, adding in prevention medicine for different infections.
The amount of polypharmacy seen in older adults with cancer is so big that pharmacists have had to make a new word for how bad the polypharmacy is. And while it would be ideal if the clinicians always had an up-to-date list, and while it must feel to patients like that computer should know what the medications are, the reality is that the medication list in our electronic medical record is frequently wrong for a variety of reasons. It changes rapidly. That list may not be updated appropriately. Patients may see providers outside of the exact system that's using that computer system, and the reality is the patient has to be the center of that wheel and make sure that the clinician has an updated list of all of those medications.
And so that's one area that the patient can really be empowered to take control of their health and particularly with these aging?associated things. The oncologist may not be thinking about their other medical conditions as being in their wheelhouse, in their domain, and if it's been stable for a long time it may not really be on their radar.
I'll give you one example. I saw a woman in consultation a few months ago who had very stable Parkinson's disease. Really not on the radar of the oncologist. Patient was given a very typical nausea medicine for nausea caused by her myeloma treatment, but unfortunately that nausea medicine interacts very badly with Parkinson's disease, and it caused her significant decline in her function because of that interaction. So not to point fingers in those situations, just meaning these situations can become complex, and the patient's other medical conditions may not be at the top of the mind of the thinking of the oncologist, especially when they're well controlled and kind of in the oncologist's mind in the background.
Lastly, maintaining function, frailty is reversible. Exercise is the key, unfortunately. I know that's hard for our patients. Between the side effects, between the symptoms of the disease itself, but staying as active as they can can be one of the best antidotes to future functional decline.
Wow. This is such a message for patients themselves who may be in their 70s, 80s, even older, and perhaps a friend or an adult child, someone who they hopefully bring to the doctor with them to really speak up. And I think our health system, as you mentioned, they may have doctors at other systems, other clinics, the medical records don't all talk to one another. They really need to help people understand what medicines they're on and always be talking about are these going to work together, or is there going to be something that's going to limit what I can do? Boy, that's so important. So it's really about the patient and the family speaking up. You can't be shy, right?
Yeah. Be empowered. And the old model of the doctor is at the helm of the ship, I tell my patients I'm not the captain of the ship, you are. I'm the navigator. I can show you what lies ahead, what pathways we might take, but yeah, to really be empowered. If the doctor faults a patient for really wanting to fully understand to ensure that these are safe medications given their overall health, that's not a good situation. That's not a good relationship to be having there. You really want to have a doctor whose openness to making sure that they're addressing all of the patient's health, not just the cancer cells in the patient.
Right, I'm sure you are, Dr. Tanya Wildes. Thank you for being with us, and I just want to underscore this for our folks. So it's all about patient empowerment, and as you said and as you spoke to physicians at the big ASCO conference, the traditional ways of thinking who is at high risk, all the testing that goes on in the lab, that gets less important as you get older and these other issues, co?morbidities, what medicines you're on, what other conditions you have, that's more important. So for those of you us who are patients and have loved ones who are patients, you got to speak up.
Dr. Tanya Wildes from the Washington University School of Medicine and Siteman Cancer Center in St. Louis, thanks for being with us on Patient Power.
Thanks for this opportunity.
I'm Andrew Schorr. Remember, knowledge and advocacy for you or a loved one can be the best medicine of all.