The concept of frailty is not new, and it has been gaining focus across various medical specialities in recent times. It is particularly important within the cohort of myeloma patients, due to the increased prevalence of frailty with older age and the globally ageing population. Frailty is a predictor of poor outcomes in myeloma, which is why it has become such an important topical theme.
The Christie at Macclesfield is a satellite unit of The Christie NHS Foundation Trust. The hospital is based in a rural location with a predominately elderly population. Frailty is therefore an important consideration in how we assess and manage our patients. We decided to run a pilot study to ascertain the most appropriate frailty score for use within the myeloma clinics. This project was run as part of Lead Macmillan pharmacist Hannah Miller’s professional doctoral research.
Calculating frailty scores
Initial background research was completed to identify both myeloma-specific and non-specific frailty tools to ascertain which could be practically used in routine clinical practice. We decided to run the pilot study using three tools: The International Myeloma Working Group (IMWG), the UK Myeloma Risk Profile (UK MRP), and the non-myeloma-specific Rockwood Clinical Frailty Scale (RCFS). These scores were deemed suitable as all the information required to calculate a score is routinely available in the myeloma clinic. The Revised Myeloma Comorbidity Index (R-MCI) and the Mayo Risk Score were deemed inappropriate due to the inclusion of lung function and cardiac function respectively, which are not routinely measured in myeloma patients.
A data collection sheet was designed and the clinicians in the myeloma clinic assessed the patients’ frailty status in addition to their routine pre-treatment assessments.
Results
Whilst this was only a small-scale study (33 patients), the results demonstrated poor consensus across the three tools. Only 35% of patients were scored in the same category with all three tools, with 26% of patients categorised differently by each tool, and 39% of patients scored the same by two of the tools. The findings highlighted that assessing frailty is not straightforward and is liable to inconsistency, even with the use of tailored frailty scoring tools.
What change was made
Although the pilot study highlighted the difficulties of frailty scoring, it did also reveal the complexity of myeloma and the need for patients to receive multifaceted support. We decided that although there were discrepancies between the scores, one tool or a combination of two tools, we would help identify the ‘frail’ cohort of myeloma patients who may benefit from additional support. We decided to use the RCFS (as this is utilised by our solid-tumour oncology colleagues at The Christie Hospital main site) and IMWG score.
We contacted Fabio Gomes, a clinical oncologist at The Christie Hospital who has a particular interest in frailty. With his help, we have plans to set up the UK’s first holistic myeloma clinic. Patients will see a myeloma specialist, a cancer pharmacist, dietician, physiotherapist and counsellor. We will then rescore the patients with both the RCFS and IMWG tools to ascertain if a holistic clinic approach has improved their frailty status.
Impact
We hope that the holistic clinic will positively impact our patients and carers at The Christie at Macclesfield. To assess this, we have conducted a patient feedback survey before the holistic clinic is introduced, and we plan to recirculate the same questionnaire. We also hope that our myeloma patients’ frailty scores will improve as a result of the holistic clinic. We also envisage that the clinic will reduce the burden of our frail myeloma patients for our GP and allied healthcare professional colleagues, as patients will no longer need to access these services separately.
“I can absolutely see the benefits of having access to a more holistic myeloma clinic, particularly with access to other healthcare professionals such as pharmacists and dieticians. I look forward to experiencing this when it is implemented.” – Myeloma patient treated at The Christie at Macclesfield
Challenges
The challenges so far have been logistical: setting up a specific myeloma clinic in a district general hospital setting, accessing allied healthcare professional support in an already overstretched and resource-limited NHS, and obtaining funding for additional allied healthcare professional roles.
Future plans
If successful, we hope to promote the UK’s first holistic myeloma clinic and help instruct and guide other haematology departments to do the same.
If you would like to find out more about the service at The Christie at Macclesfield, please contact the CSEP Team at csep@myeloma.org.uk
Written by Hannah Miller
Lead Macmillan Pharmacist
The Christie at Macclesfield