Identifying Between Smoldering and Active Myeloma

Transcript: A. Keith Stewart, MB, ChB: Hello, and thank you for joining this OncLive Peer Exchange® discussion titled “Refining Systemic Therapy for Multiple Myeloma.” With a plethora of FDA-approved regimens for the treatment of multiple myeloma, a personalized approach is the key to obtaining deeper and more durable responses for both newly diagnosed disease and in the relapsed setting. In this OncLive Peer Exchange® panel discussion, we’ll be looking at new data, including that presented at the ASH 2018 meeting, to shed light on how to improve outcomes for patients.

I am Dr Keith Stewart, the Vasek and Anna Maria Polak Professor of Cancer Research at the Mayo Clinic in Phoenix, Arizona.

And joining me today are Dr Tom Martin, professor of medicine and co-director of the Myeloma Program at the UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco, California; Dr Faith Davies, professor of medicine and deputy director of the Myeloma Institute at the University of Arkansas for Medical Sciences in Little Rock, Arkansas; Dr Rafael Fonseca, professor of medicine and chair of the Department of Medicine at the Mayo Clinic in Phoenix, Arizona; and finally, Dr Adriana Rossi, associate clinical director of the Multiple Myeloma Center and assistant professor of medicine at the Weill Department of Medicine, Weill Cornell Medical College in New York City, New York.

I look forward to a great discussion, so let’s begin.

We’re going to start by talking about the treatment of newly diagnosed patients. And there’s some controversy, Faith, about who should be treated today and how early. There seems to be a trend toward treating patients earlier in their disease course. What triggers that decision in your mind, and who would you call smoldering versus active myeloma?

Faith Davies, MD, MBBCh, MRCP, FRCPath: Recently there’s been a movement to treating early, and there’s been some confusion I guess about what the definition of smoldering myeloma is and what the definition of active myeloma is. And so I think we’re now really taking note of patients and components, potentially those patients with a high IgA [immunoglobulin A], we’re going to think about treating early. We need to obviously look at that bone marrow plasma cell percentage, their light chain. But also I think maybe just looking at the M component over time and ensuring whether it is stable or whether it’s shifting a little bit. And really trying to get in there early before patients develop any end-organ damage is key. But also, making sure we’re not overtreating those patients that really don’t need therapy. So it’s a little bit tricky.

A. Keith Stewart, MB, ChB: Would anybody else on the panel have an opinion about who should be treated early versus waiting?

Thomas Martin, MD: Well I will echo what Faith said, and that is, for smoldering myeloma patients, those that don’t have any CRAB symptoms, I don’t look at the snapshot the one time I’ve seen that patient. I really want to see the movie — what’s happening over the 3 months or the first 6 months. If they have the evolving M protein, meaning that it’s rising, and there’s a 10% rise over subsequent values, those people, I do think they need to be treated.

You know treatment for smoldering myeloma I think for all of us should be done on a clinical trial. However, if you don’t have a clinical trial, I would initiate therapy, especially in people that have this rising M protein.

Rafael Fonseca, MD: And if I could interject, I think this is an area that deserves a lot of attention because we don’t want our patients to have complications. And particularly the 2 dreaded complications are bone disease and renal problems. And just a year ago Ola said that we probably should get away from this smoldering classification. I’m going to say that I actually agree with him. We need to identify those patients that are right there at the cusp of potential progression, which need to be monitored very, very closely. And those that really are smoldering with 15%, the low free light chain, I mean do we tell that person that they’re the same as someone who has 50% plasma cells? The answer is, no. So I think we might need to move into a world where, for which myeloma that is almost ready to be treated, we particularly pay attention to those patients.

Transcript Edited for Clarity