DISCUSSION
MM
RECRUITMENT
There is no consensus on the treatment of elderly patients with MM in real‐world practice, although clinical trials have proven the efficacy of novel agents in MM. The management of elderly MM is challenging due to various comorbidities and compromised health status, generally ineligible for clinical trials limiting the evidence for the elderly.Under the guidance of the CEMM2021 model based on elderly patients' general condition, less than 20% of elderly NDMM are eligible to initiate the continuous Rd regimen as frontline therapy, which was solidly supported by the FIRST trial.On the other hand, by bortezomib‐based primary treatment, the majority of elderly NDMM in the study, not satisfying all the strict criteria mentioned above to initiate Rd, achieved comparable response and survival benefits. Similarly, a real‐world study in transplant‐ineligible NDMM from Spain revealed that bortezomib‐containing regimens (81.7%) were the most commonly prescribed primary therapy, and only 3.6% of patients received the Rd regimen.It is also noteworthy that the management of older patients with MM, presenting a highly heterogeneous nature, is often challenging due to insufficient recruitment for clinical trials. And data in real‐world settings are not yet sufficient to meet the demand, specifically, merely based on only a few reports that enrolled several hundreds of elderly NDMM patients among the globally dispersing medical centers and one Canadian study enrolled 1156 transplant‐ineligible MM from the national web‐based database.This study also confirmed that for elderly patients with MM, the proportion of BM‐derived Bregs is related to the OS, while the proportions of Bregs and SUVmax were significantly associated with OS but not PFS, which was similar to our previous studies.The CEMM 2021 treatment model provides a solid basis for small molecular inhibitors for elderly cases with MM and requires an urgent upgrade to improve survival for currently diagnosed patients in the near future. To be specific, the treatment of MM has entered the era of cellular immunotherapy and antibody‐containing immunotherapies have been recently recommended as the frontline therapy for the elderly MM by the guidelines.