When should myeloma treatment be started?

So when do our patients start treatment?

Myeloma is defined by the acronym CRAB, which stands for C for elevated calcium in the blood, R for renal failure, A for anemia, and B for bone disease.

In addition, we've also introduced three new biomarkers that qualify for a diagnosis of multiple myeloma. They include a highlighted gene reshoot presence of more than one focal lesion seen on MRI and more than 60% plasma cells in the bone marrow.

Currently, if the patient meets any of these criteria, they are considered to have multiple myeloma and will need full myeloma treatment, which includes induction, eligibility for transplant, followed by consolidation in certain circumstances, and maintenance therapy.

The majority of newly diagnosed patients are those who have come to evaluation from a healthcare provider because they have symptoms, fractures, anemia, or kidney failure. On average, we should try to treat them as soon as humanly possible, and much sooner than many patients often get the opportunity to be treated.

We would love patients, if they get diagnosed with fractures, anemia, and kidney failure in the hospital, to start treatment immediately to prevent further damage and to allow recovery of those organs that are damaged. But that's not always the case.

Some patients meet criteria for myeloma, sometimes the so-called slim criteria—greater than 60% plasma cells, greater than one focal lesion on MRI. These patients have met criteria for myeloma diagnosis, but they have a 75% chance of developing CRAB criteria in two years.

These patients are different. They're not clinically sick at the time. So you may have a moment to think about it, delay a bit, and think about it. Is there a clinical trial close by? Consider the timing for the patient and try to get your ducks in order before starting treatment.

For these patients, you have some flexibility, whereas those patients who will have fractures and kidney failure in the hospital, you want to get them started right away.

When should smoldering myeloma patients start treatment?

For patients who need to start treatment, timing is really critical.

We don't want to start too early for patients who don't need it. We were talking about patients who have MGUS or that little bit of M protein but don't actually have myeloma or even patients with smoldering myeloma.

We have categories of clinical symptoms and clinical tests that we can look at to call someone high-risk smoldering or low-risk smoldering. What smoldering really means, or asymptomatic myeloma, is that patients don’t have organ involvement yet.

We want to treat patients before they have organ involvement because we don’t want them to have broken bones or kidney issues or anything. We also don’t want to treat too early if they’re going to do really well for many years before we start treatment. With each treatment, there's resistance.

There's a big push to find those patients who are really high-risk and are about to have myeloma that’s going to cause clinical issues. We should treat those patients before it becomes that way.

For most of my patients, we actually talk about clinical trials. If someone has a smoldering high-risk phenotype and is interested, we go ahead and do that as a standard of care.

We have lenalidomide treatment right now as the one FDA-approved treatment for smoldering high-risk patients.

The question is, do you want to take something right now, or do you want to watch it very carefully? The second we see it becoming myeloma, we go ahead and start full therapy then.

So I think the fact that we have something as a standard of care, but most people aren't using it yet, is because of the angst of wondering, "Are you really going to have myeloma in two years, five years, or ten years?" And do we just want to watch it very carefully?

I think the most important part is that, yes, we want to treat you before you have clinical symptoms that are causing quality of life issues. However, we don’t have the best tools to know which patients really need treatment right then and there.

That discussion with your doctor is really important. If you have high-risk smoldering myeloma, asymptomatic myeloma, you need to make sure you're being followed regularly—not once a year, not even every six months, but maybe every three months. Keep a close eye on those labs, because if they’re going up, it means we probably need to go ahead and start treatment.