Utilizing a two-step frailty assessment strategy in older adults with multiple myeloma (MM): A decision curve analysis.

person Andrew Gahagan Department of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL info_outline Andrew Gahagan, Monica Sai Pasala, Clare Ubersax, Abigail Tucker, Christian Harmon, Susan Bal, Kelly Nicole Godby, Gayathri Ravi, Luciano J. Costa, Grant Richard Williams, Smith Giri

Authors person Andrew Gahagan Department of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL info_outline Andrew Gahagan, Monica Sai Pasala, Clare Ubersax, Abigail Tucker, Christian Harmon, Susan Bal, Kelly Nicole Godby, Gayathri Ravi, Luciano J. Costa, Grant Richard Williams, Smith Giri Organizations Department of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, University of Alabama at Birmingham, Birmingham, AL, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, Department of Medicine, Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL Abstract Disclosures Research Funding No funding received None. Background: The International Myeloma Working Group Frailty Index (IMWG-FI) has been shown to predict risk of toxicity and mortality in older adults with MM (Palumbo et al., Blood 2015). However, IMWG-FI requires a geriatric assessment (GA) that is not routinely done in clinical practice due to time constraints. A simplified frailty index (SFI; Facon et al., Leukemia 2020) has been proposed as an alternative using ECOG PS as a proxy to functional status. We previously reported a moderate concordance between these two frailty indices (Kappa statistic 0.50; Gahagan et al., ASH 2022). Here, we examined if SFI can be utilized as a screening tool to identify patients who would benefit from a formal GA and frailty assessment. We hypothesized that a two-step approach would minimize the need for unnecessary GAs, while saving time in clinical practice. Methods: For this analysis, we included patients ≥50yo with newly diagnosed (ND) or Relapsed/Refractory (RR)-MM at a single institution initiating a new treatment regimen (1 st to 6 th line) who are enrolled in a prospective registry (NCT05556928). All patients underwent a GA prior to a new line of therapy. ECOG PS and comorbidities were abstracted from medical records. We calculated IMWG-FI and SFI using published methods. Sensitivity, specificity along with their 95% CI were calculated for both SFI and IMWG-FI, using published SFI cutpoints. Lastly, we used decision curve analysis (DCA) as described by Vickers et al. to calculate the benefit of frailty screening using SFI for detection of non-frail patients and avoiding unnecessary GAs. We assumed that reasonable threshold probabilities were 0.25 and 0.33 respectively indicating that missing an unfit patient was 3 and 2 times worse than exposing a fit patient to an unnecessary GA (odds of 1:3 and 1:2 respectively). We quantified the net benefit (NB) of this two-step frailty assessment versus GA-for-all in terms of net reduction in unnecessary GAs. Results: A total of 146 adults with MM (49 ND-MM, 51 pre-transplant, and 46 RR-MM) starting a new line of therapy between 8/2020-1/2022 were included in this study. The median age was 62 (IQR 57-70) with 53% males and 36% blacks. The distribution by IWMG-FI was 43% fit, 32% intermediate-fit, and 25% frail. Using SFI, 32% of patients were frail. Using a cutpoint of ≥2, SFI as a screening tool had a sensitivity of 89.2% (95% CI 75-96%) and a specificity of 65% (95% CI 56% to 73%). DCA showed that selecting candidates for GA based on a two-step strategy (SFI followed by IMWG-FI) led to an absolute 40-45% reduction in the number of unnecessary GAs without missing any frail patients. Conclusions: Our results suggest that using a two-step frailty assessment strategy of SFI as a screening tool followed by confirmation with IMWG-FI reduces the need for unnecessary GAs by 40-45% and may be more suitable for integration in busy oncology practice.

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