Integrating biology, frailty, and patient values: The 5M framework for older adults with multiple myeloma

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.