Multiple myeloma (MM) predominantly affects older adults, in whom frailty, comorbidities, and psychosocial factors complicate treatment decision-making. Existing tools, including the International Myeloma Working Group (IMWG) frailty score and comprehensive geriatric assessment (CGA), provide valuable insights but do not offer a structured approach that integrates disease biology, treatment feasibility, and patient values. To address this gap, we developed the 5M Framework for Older Adults with Multiple Myeloma (5M-OMM), a five-domain model that supports stepwise, multidisciplinary decision-making. The framework first defines a biologically informed strategy aligned with patient priorities and then incorporates functional, psychological, and social factors to refine the treatment plan. Application to representative clinical cases illustrates how selecting initial therapy according to disease biology and patient priorities, followed by adaptation to frailty and comorbidity burden, can improve feasibility and reduce the risk of undertreatment when frailty tools are used in isolation. The 5M-OMM complements existing geriatric oncology approaches by providing a practical structure for reassessment and multidisciplinary shared decision-making in older adults with MM.
Primary central nervous system lymphoma (PCNSL) is an aggressive disease with heterogeneous clinical outcomes, and readily measurable prognostic biomarkers remain limited. We retrospectively analyzed 21 patients with newly diagnosed PCNSL who received high-dose methotrexate-based therapy at a single institution between 2006 and 2023. The median age was 68 years, and 12 patients had deep-structure involvement. Median overall survival (OS) and progression-free survival were 41 and 31 months, respectively. In univariate analyses, pretreatment serum soluble interleukin-2 receptor (sIL-2R) level (p = 0.0185), cerebrospinal fluid protein level (p = 0.0401), and receipt of radiotherapy (p = 0.0377) were significantly associated with OS. Receiver operating characteristic analysis of pretreatment serum sIL-2R for 3-year OS yielded an area under the curve of 0.869; a candidate threshold of 566 U/mL showed a sensitivity of 85.7% and specificity of 83.3%. Pretreatment serum sIL-2R was associated with OS in this small retrospective cohort, and this exploratory finding warrants validation in larger independent studies.
Refusal of blood transfusion has historically been associated with members of the Jehovah’s Witness (JW) faith. As such, a range of transfusion-sparing strategies have been developed for these individuals and others who refuse standard blood transfusion. Techniques that maintain blood in continuous circuit with the patient are often acceptable and have been used in operative settings, including cell salvage and acute normovolemic hemodilution. By contrast, blood that has been collected and stored for later use has traditionally been considered unacceptable, which has limited the use of both allogeneic and autologous blood products. A March 2026 update by the governing body of Jehovah’s Witnesses, The Watch Tower Bible and Tract Society of Pennsylvania, moves decisions about the storage and reinfusion of a patient’s own blood into the realm of individual conscience, which may expand the use of autologous transfusion. Given this change, requests for autologous transfusion from JW patients may increase. In this letter, we offer practical guidance on balancing respect for patient autonomy and religious belief with the medical and logistical challenges of autologous blood transfusion.
HFE -related hemochromatosis (HC) is caused by hepcidin dysregulation and is characterized by excessive iron absorption and accumulation in the liver, heart, and endocrine glands, which leads to complications including arthropathy, cirrhosis, and hepatocellular carcinoma. Standard of care (SoC) typically involves phlebotomy, with iron chelators used less frequently. However, these therapies may cause side effects and negatively impact quality of life, making them troublesome for some patients. Using the Delphi methodology, a survey was developed to identify unmet needs and clinical challenges within the current therapeutic landscape of HC, and to establish consensus statements for its management. Consensus was defined as ≥75% agreement. Thirty-two HC specialists from Europe, Australia and the USA responded to the survey. After three rounds of survey refinement, final consensus statements were compiled. The Delphi process identified key unmet needs in HC, including lack of alternatives to phlebotomy, persistent symptoms, and burden related to the use of current SoC. The consensus process helped establish definitions for high phlebotomy treatment burden, intolerance, and suboptimal response to phlebotomy. The process also identified the subgroup of patients overly burdened by phlebotomy. Patient-reported outcomes were considered key to assessing phlebotomy’s impact, although they are rarely measured in clinical practice. The Delphi study highlighted the limitations of phlebotomy, with respondents identifying a high unmet need for patients who cannot be managed with or do not tolerate this approach. The study suggested exploring alternative therapy options for patients who experience high treatment burden or intolerance to phlebotomy.
Iron deficiency is the most common micronutrient deficiency worldwide, affecting approximately 2 billion individuals. Iron deficiency without anemia (IDNA), the stage in which iron stores are depleted but hemoglobin remains within the reference range, is estimated to affect approximately 1-2 billion individuals, although the precise prevalence varies by population, ferritin threshold, and inflammatory status. IDNA remains underrecognized because diagnostic evaluation often focuses on hemoglobin concentrations rather than iron stores. A growing body of evidence demonstrates that IDNA is associated with clinically significant fatigue, impaired cognitive function, anxiety, reduced exercise capacity, and diminished quality of life. Randomized controlled trials and meta-analyses of iron repletion in iron-deficient non-anemic cohorts demonstrate clinically meaningful reductions in fatigue. Emerging observational data have also identified an association between iron deficiency and colorectal neoplasia in selected higher-risk populations such as older adults, men, and postmenopausal women. However, the magnitude of this risk and the role of routine endoscopic evaluation in patients with IDNA remain incompletely defined. This narrative review examines the epidemiology, pathophysiology, origins of under-recognition, clinical manifestations, diagnostic approach, treatment, association with colorectal cancer, and future directions for IDNA in adults.
