Multı̇pl mı̇yelom tanılı hastalarda CARG ve CRASH kemoterapı̇ toksı̇sı̇te skorlarının değerlendı̇rı̇lmesı̇
Evaluation of CARG and CRASH chemotherapy toxicity scores in patients with multiple myelom
Yazar: HAKAN ÖZÇELİK
Danışman: DOÇ. DR. ELİF GÜLSÜM ÜMİT
Trakya Üniversitesi / Tıp Fakültesi / İç Hastalıkları Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2023
Konu: Hematoloji = Hematology

Özet:
Kronik bir hastalık olan multipl miyelom da tedavinin amacı hastanın yaşam kalitesini ve yaşam süresini koruyarak sağkalımı uzatmaktır. Çalışmamızın amacı, kanser tanısı sonrası tedavinin bireyselleştirilmesi için geliştirilen ayrıntılı değerlendirme yöntemlerinin MM tedavisindeki yerini ve önemini ortaya koymaktır. Bu çalışmada, multipl miyelom tanılı hastalarda CARG ve CRASH kemoterapi toksisite skorlarını Savunmasız Yaşlılar Anketi-13, Geriatrik Tarama Testi, Mini Beslenme Değerlendirmesi, Lowton-Brody ölçeği, polifarmasi ve ECOG performans durumuna göre değerlendirerek yaşam kalitesini belirlemede olan etkinliklerini değerlendirmeyi amaçladık. Çalışmamıza Trakya Üniversitesi Tıp Fakültesi Hematoloji Bilim Dalı Polikliniği'nde takip edilen, 2021-2022 yılları arası başvuran, multipl myelom tanılı 60 hasta dahil edildi. Hastaların performans durumu "Eastern Cooperative Oncology Group" performans skalası kullanılarak değerlendirildi. Çalışmaya alınan tüm hastalara Savunmasız Yaşlılar Anketi-13, Geriatrik Tarama Testi, Mini Beslenme Değerlendirmesi ve Lawton ve Brody Günlük Yaşamın Enstrümantal Aktiviteleri Ölçeği uygulandı. CRASH skorlama sistemi kırılganlık ile değerlendirildiğinde, VES13 ile kırılgan olduğu tespit edilen 25 hastanın 13'ü yüksek, 10'u ise orta-yüksek risk grubunda idi ve bu dağılım istatistiksel olarak anlamlı olarak gözlendi (p=0.000). Polifarmasi ile birlikte değerlendirildiğinde yüksek CRASH skoru olan 13 hastanın tamamında polifarmasi izlenir iken, düşük gruptaki 16 hastanın 5 inde polifarmasi olduğu gözlendi ve bu dağılım istatistiksel olarak anlamlı bulundu (p=0.001). Sağlık durumu değerlendirme ölçeği G8 ele alındığında sağlık durumu normal bulunan 22 hastanın yalnızca 3'ü yüksek riskli iken, sağlık durumu bozulmuş bulunan 38 hastanın 10'u yüksek, 10'u orta yüksek, 12'si orta düşük bulundu ve bu dağılım istatistiksel anlamlı olarak gözlendi (p=0.008).
CARG Skoru geriatrik değerlendirme bileşenlerinden olan kırılganlık değerlendirme ölçeği VES13 ile ele alındığında, kırılgan olmayan 35 hastanın 32'si düşük CARG skoru gösterir iken, kırılganlık izlenen 25 hastanın 17'sinde yüksek, kalan 8'inde ise orta CARG skorları gözlenmiştir ve istatistiksel olarak anlamlılık izlenmiştir (p=0.000). Polifarmasi tespit edilen 41 hastanın 16'sı yüksek CARG skoru, 7 si orta, 18'i ise düşük risk grubunda yer alır iken, polifarmasi tespit edilmeyen 19 hastanın 14'ü düşük CARG risk grubunda yer almıştır. Bu dağılım istatistiksel olarak anlamlı bulunmuştur (p=0.024).
CARG skorunun gücünü, G8 sağlık değerlendirme anketi ile kıyasladığımızda G8 sağlık durumu bozulmuş bulunan 38 hastanın yalnızca 15'i düşük CARG grubunda iken, G8 sağlık durumu etkilenmemiş bulunan 22 hastanın 17'sinin düşük CARG grubunda olduğu izlenmiştir ve bu dağılım, istatistiksel anlamlı bulunmuştur (p=0.018). ECOG performans durumu gibi etkinliği ispatlanmış bir değerlendirme yönteminin CARG skoru ile karşılaştırmasında ECOG 3-4 olan hastaların hemen tamamı orta-yüksek CARG skoru göstermiştir, bu dağılım istatistiksel olarak anlamlıdır (p=0.007).
Hematolojik kanserlerde tedavi öncesinde CARG ve CRASH skorlarının bakılması ve buna göre geriatrik değerlendirmenin zenginleşmesi gereği önemlidir. Bizim çalışmamızda da CARG skoru, CRASH skoru ile birlikte anlamlı bulunmuş, VES13 ve G8 gibi sağlık değerlendirme ölçekleri ile ilişkili gözlenmiştir.

Abstract:
The aim of treatment in multiple myeloma, which is a chronic disease, is to prolong survival by preserving the patient's quality of life and life expectancy. The aim of our study is to reveal the place and importance of detailed evaluation methods developed for the individualization of treatment after cancer diagnosis in the treatment of MM. In this study, we aimed to evaluate their effectiveness in determining quality of life by evaluating CARG and CRASH chemotherapy toxicity scores in patients with multiple myeloma according to Vulnerable Elderly Questionnaire-13, Geriatric Screening Test, Mini Nutritional Assessment, Lowton-Brody scale, polypharmacy and ECOG performance status.
Our study included 60 patients diagnosed with multiple myeloma, who were followed up in the Hematology Department of Trakya University Faculty of Medicine, and applied between the years 2021-2022. The performance status of the patients was evaluated using the "Eastern Cooperative Oncology Group" performance scale. Vulnerable Elderly Questionnaire-13, Geriatric Screening Test, Mini Nutrition Evaluation, and Lawton and Brody Instrumental Activities of Daily Living Scale were administered to all patients included in the study.
When the CRASH scoring system was evaluated with frailty, 13 of 25 patients who were found to be frail by VES13 were in the high risk group and 10 were in the medium-high risk group, and this distribution was statistically significant (p=0.000). When evaluated together with polypharmacy, polypharmacy was observed in all 13 patients with high CRASH scores, while polypharmacy was observed in 5 of 16 patients in the low group, and this distribution was statistically significant (p=0.001). Considering the health status assessment scale G8, only 3 of 22 patients with normal health status were at high risk, while 10 of 38 patients with impaired health status were found to be high, 10 were moderately high, and 12 were moderately low, and this distribution was statistically significant. observed (p=0.008).
When the CARG Score is evaluated with the frailty assessment scale VES13, which is one of the components of geriatric assessment, 32 of 35 non-fragile patients showed low CARG scores, while high CARG scores were observed in 17 of 25 frailty patients and moderate CARG scores in the remaining 8 patients, and statistical significance was observed. (p=0.000). While 16 of 41 patients with polypharmacy were in the high CARG score, 7 were in the moderate and 18 were in the low risk group, 14 of the 19 patients without polypharmacy were in the low CARG risk group. This distribution was found to be statistically significant (p=0.024).
When we compared the strength of the CARG score with the G8 health assessment questionnaire, only 15 of 38 patients with impaired G8 health status were in the low CARG group, while 17 of 22 patients with unaffected G8 health status were in the low CARG group, and this distribution was statistically significant (p. =0.018). In comparison with the CARG score of a proven evaluation method such as ECOG performance status, almost all patients with ECOG 3-4 showed a moderate-high CARG score, this distribution is statistically significant (p=0.007).
It is important to check the CARG and CRASH scores before treatment in hematological cancers and to enrich the geriatric evaluation accordingly. In our study, the CARG score was found to be significant together with the CRASH score, and it was observed to be associated with health assessment scales such as VES13 and G8.