《肿瘤瞭望》：多发性骨髓瘤的中位发病年龄为70岁左右，年龄是MM重要的预后因素，您是否有界定单纯年龄大于多少的患者不适合做进一步的化疗？

　　Mateos教授：没有，正如你所说，多发性骨髓瘤好发于老年患者，其中位诊断年龄为65~70岁。所以对于所有患者来说，不管年龄如何都能接受合适的化疗。问题是我们必须去评估患者的耐受性、合并症、以及疾病的分子生物学表型，从而以却确定最佳的治疗方案。总体上来说，所有的患者都应该接受合适的化疗。

　　I don’t think so. Multiple myeloma usually affects the elderly population and as you said， the median age for multiple myeloma at diagnosis is between 65 and 70 years of age. So all patients， regardless of age can receive an appropriate chemotherapy. The problem is that we have to evaluate the biological and chronological age of comorbidities and the performance status to identify which is the best option for therapy according to the patient’s frailty status. But generally， all myeloma patients can be potential candidates to receive effective combinations of therapy.

　　《肿瘤瞭望》：是否有老年多发性骨髓瘤患者对应的耐受性评估体系？

　　Mateos教授：答案是确定的，尤其对于年龄65~70岁或以上的患者，评估其耐受性是非常必要的。我们必须确定这个患者是否适合化疗，身体状况如何，从而选则具体的化疗方案。举例来说，对于老年适合化疗的患者，我会选择地塞米松每周40 mg；但是如果不适合者则可以下调剂量，给予每周20 mg；如果患者身体羸弱，则不应该给地塞米松，而应该给予泼尼松。我们必须把所有的新药都考虑进去，包括硼替佐米、沙利度胺、来那度胺，根据患者的耐受性来决定最佳的治疗方案。

　　The answer is definitely yes. It is necessary when we have a patient with myeloma in front of us older than 65 or 70 to evaluate the patient’s frailty status. We have to identify whether the patient is fit， unfit or frail so we can modify the chemotherapy regimen according to this frailty status. I can explain this with a very simple example. Fit elderly patients can receive dexamethasone 40mg weekly， but if unfit， should probably receive 20mg weekly. If the patient is frail， dexamethasone should probably not be given and should be replaced by prednisone. This is what we have to do with all new agents that we are incorporating into the treatment of multiple myeloma including bortezomib， thalidomide and lenalidomide and so on， to optimize the treatment according to the frailty status.

　　《肿瘤瞭望》：在老年多发性骨髓瘤患者中，来那度胺+地塞米松的治疗方案是否可以替代经典的MP方案？

　　Mateos教授：来那度胺的确优于MP方案。因为来那度胺是免疫调节剂可以和低剂量地塞米松联用，FRIST实验已经显示其效果优于MP方案。在西班牙的实验中我们比较了VMP和VTP，结果VMP优于VTP。所以马法兰是优于沙利度胺的，然而比较组是沙利度胺而不是来那度胺，所以我认为在欧洲最有效的方案是以硼替佐米为基础的方案，VMP是其中之一。其他最有效的方案是来那度胺联合低剂量地塞米松。因此可以针对耐受性良好的老年骨髓瘤患者可以把这些方案结合起来，选择序贯或其中之一的方案以尝试去提高患者的PFS和OS。

　　Lenalidomide is certainly better than melphalan plus prednisone because lenalidomide is an immunomodulatory agent and in combination with low-dose dexamethasone has continued to demonstrate superiority to the MP combination (melphalan plus prednisone plus thalidomide) in the first trial. In our Spanish trial where we compared VMP with VTP， our conclusion was that VMP was superior to VTP. So melphalan was superior to thalidomide. However， in the comparator arm there was thalidomide but no lenalidomide， so I think that the most efficient regimen for elderly patients with multiple myeloma is probably the bortezomib-based combination and here in Europe， VMP is one of them. The other most efficient regimen to be used in elderly patients is lenalidomide with low-dose dexamethasone. We can put these together in a sequential or alternating approach for fit elderly myeloma patients to really try to improve progression-free survival and overall survival.

　　《肿瘤瞭望》：蒽环类药物是否适用于老年患者？

　　Mateos教授：蒽环类药物对于多发性骨髓瘤是有效的。然而，必须要十分警惕其对心脏的毒性，尤其对于老年人。我们能否使用呢？答案是可以的。但是考虑到我们有可以避免心脏副作用的其他药物，蒽环类药物当然不是我们治疗患者的首选药。总结来说，我们可以选择蒽环类药物，但是可以选择其他同样有效且没有心脏毒性的药物。

　　Anthracyclines are effective in the treatment of multiple myeloma patients. However， we have to be careful with some issues particularly the cardiac toxicity of anthracyclines in all patients but specifically in elderly patients with multiple myeloma. Can we use it? Yes. But considering that we now have other possibilities that avoid the use of anthracyclines and the cardiac side effect profile and consequent cardiac events， why would we? In summary， we can use the anthracyclines， but there are other possibilities that are equally effective without the potential cardiac side effect issues.

 

编辑：张国建