What are the two approaches to treating smoldering myeloma?

What are the two approaches to treating smoldering myeloma?

So again it goes back to do you believe smoldering myeloma is just the a precursor to active myeloma in all cases, or are there some people that will always remain in that smoldering phase and never become active? If you're a believer in that smoldering myeloma, patients require some other hit or some other mutation or something happens that makes them go into an active phase. You may want to just do something to try and do as much as possible to keep them in that smoldering phase. And I think that's where the idea of maybe using an immune modulating drug like Revlimid, where you just change or maybe alter the immune system environment enough to keep that disease in that smoldering phase maybe sufficient and you don't put the patient through a lot of the toxicity of active myeloma therapy. If your myeloma actually is just on its way to active eventually and it's a precursor and it's going to be acquiring mutations as it moves along the way, perhaps is this is the time when we should had a really hard and just eradicated it. That's what we talk about when you have active myeloma get your best therapies all at once. That is the idea behind people who are very aggressive like the GEM-CESAR trial from Spain or perhaps in the smoldering phase, we should be hitting them with all our active drugs, including transplantation and consolidation maintenance because that is our best chance to actually be eradicated. And so, again, it goes back to that camp of do we think this is the same disease or not? In general, If you look at smoldering myeloma, there are different clinical trials that are ongoing. There are some that are on one spectrum. Let's treat it as overt myeloma. So let's use three drugs four the drugs. Carfilzomib, Len, Dex transplant is one of the options. Daratumumab, Carfilzomib, Len, Dex is another option. These are on the extreme end of let's treat it as overt myeloma and we will get to know the answers from this. We have data from it. MRD negative disease looks very exciting. The question is, is there an opportunity for us not to use all of those drugs of myeloma in a patient who does not have all of the symptoms and the tumor burden of myeloma? The other extreme are things like a single agent antibody. There is Daratumumb, single agent, and I think that's interesting. Or Lenalidomide, single agent. It's interesting, it's good. But is it the right thing to use a single agent in those patients? And I think both are correct. There is no wrong answer, but maybe there is no right answer in both of them. I think we need something called precision intervention, where not all smoldering myeloma are the same. Not all of them should be treated either with this or that. Let's redefine them correctly and certain patients should get three or four drugs, should be treated like overt myeloma to prevent clonal selection, certain patients Len alone or an antibody alone would be perfect for them. It will delay progression. It will give them an amazing response and progression free survival without making them exposed to all those drugs. And then what we are trying to think now is can we develop immunotherapy, true immunotherapy for certain groups of patients that we can make a difference in their survival without exposing them to all of the drugs of myeloma. Whether to treat Smoldering myeloma or not is an area of active research and much controversy. Treatment for smoldering multiple myeloma is a complex issue that depends on the individual patient's risk. There is no consensus on whether or not to treat SMM, and the current standard of care is to monitor patients for progression to active multiple myeloma, which may take many years. This approach is based on the idea that patients with low or standard risk SMM may not need treatment. Some suggest that treatment should be considered for selected high-risk smoldering myeloma patients. But this is still very controversial. A survey of clinicians found that 92% of them recommend against treating high-risk smoldering multiple myeloma.