BETA - What is risk stratification?

[Music] what is risk stratification so what is meant by risk stratification risk stratification refers to testing that we do usually when a patient is first diagnosed with multiple myeloma in order to help determine their overall prognosis and get some sense of the aggressiveness of their myeloma and it usually entails both laboratory tests often done in the blood such as beta-2 microglobulin lactate dehydrogenase or LDH an albumin as well as tests from the bone marrow biopsy called cytogenetics these are looking for chromosomal changes within the myeloma cells that can be predictive of the cells behavior we've known for some time now that the myeloma cells can have certain chromosome changes that can predict either for more aggressive or less aggressive and so based on all of those tests we can come up with a risk status of the patient as either standard risk or high risk myeloma how is risk determined and how does risk a guide treatment so this is a very controversial area right now and one where there's a lot of research going on but there are certain abnormalities within the bone marrow chromosomes that lead to what we call higher risk disease the higher likelihood that the disease either won't respond to and your treatments or will respond that only for a short duration of time and so we are sometimes able to use this risk stratification information to tailor the treatment to the patient in some cases this means we'll not use a different initial regimen more aggressive therapy or in some cases we may recommend a different type of maintenance therapy perhaps two different drugs used together rather than one drug if the patient has high-risk disease in addition there are a number of clinical trials now going on that are specifically focusing on patients who have some of the higher risk side of genetics or higher risk laboratory abnormalities to try to see we can change our interventions perhaps to get better outcomes in this group of patients so that's how we're using the information more and more we're using cytogenetic data to really predict how an individual may do but I want to emphasize the fact that it is truly a prediction or a prognostic tool what I mean by that is when we look at all the factors when somebody presents with myeloma we look at clinical factors in terms of what the stage of their disease might be what the symptoms it may be getting from their disease what organ dysfunction they have from their disease all those factors matter when we think about initial therapy and what benefits image arrived from that initial therapy some genetic profile has been used now as part of our staging system mainly because when you group patients that have some cytogenetic abnormalities and you look at outcomes they do differ in terms of how well they might do whether they have standard risk or high risk cytogenetics based on the mutational profile that they have in their bone marrow however we've all seen cases where that doesn't always hold true so you have patients that conceivably have some of the higher risk higher risk cytogenetics that actually end up having a great response to therapy and a very long duration of remission and conversely we have patients that at least on paper looked like they had very standard grisaille low genetics that end up having more refractory disease so I always tell patients you know it is very easy to just kind of fixate on one or two separate things and they kind of look at that as the end-all be-all but I think again myeloma is very unique you have to think about you can always those factors and sometimes you use them to make treatment decisions but that also doesn't supersede what actually happens to look forward so when I meet with patients they've had it great let's say they have a 17p deletion which is considered one of the higher risk myeloma so genetic abnormalities but they've had a great response to therapy whether that includes a stem cell transplant or not we're all constantly faced with this question well you know that's what I was diagnosed with but I'm doing well you know I basically tell them that you know this it's not perfect system we don't have all the information at this time and we use some of these tools to guide patients and guide ourselves we might do for an individual but that by no means is the end-all be-all for an individual patient so the risk stratification in myeloma is primarily driven by the presence of genetic abnormalities or the abnormalities found the fish testing in addition there are some laboratory variables including the LDH as well as the ISO staging system that also drives the outcome in these patients so using all these ones we can identify certain patients were the survival both the progression-free survival and the overall survival can be significantly shorter compared to the average patient and these are the patients who may prefer to as high-risk multiple myeloma roughly about 15 to 25% of the patients will be considered to have high risk myeloma use in their current stratification systems [Music]