EHA 2023 | To treat or not to treat smoldering myeloma & identifying patients at risk of progression to myeloma
Karthik Ramasamy, MBBS, MRCP, FRCPath, PhD, Oxford University Hospitals NHS Foundation Trust, Oxford, UK, comments on the current and future management of smoldering myeloma. Whilst the “watch and wait” strategy is still mostly used in Europe, NCCN guidelines recommend including patients in trials or considering lenalidomide-based therapy. Dr Ramasamy explains that strategies to identify patients at risk of progressing to active myeloma are emerging and will help identify who might benefit from treatment. This interview took place at the 28th Congress of the European Hematology Association (EHA) 2023 in Frankfurt, Germany.
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Transcript (edited for clarity)
So ‘watch and wait’ is what we do for smoldering myeloma patients currently, at least in Europe. Although the NCCN guidelines in the US do have a recommendation to include patients in trials or consider lenalidomide-based therapy, based on the two Phase II trials. The high prevalence of use of ‘watch and wait’ in the rest of the world is really the question around who do we treat? And the understanding around who the high-risk myeloma is continuing to be worked out...
So ‘watch and wait’ is what we do for smoldering myeloma patients currently, at least in Europe. Although the NCCN guidelines in the US do have a recommendation to include patients in trials or consider lenalidomide-based therapy, based on the two Phase II trials. The high prevalence of use of ‘watch and wait’ in the rest of the world is really the question around who do we treat? And the understanding around who the high-risk myeloma is continuing to be worked out. One very useful clinical criteria that the IMWG consensus has emerged is around the use of the 20-20-20 criteria: around 20% plasma cells, 20g/L paraprotein and 20 serum-free light chain ratio. At least what it does is it’s able to help us understand a group of patients who’ve got close to, kind of, 60 to 70% risk of progression, to active multiple myeloma in two years. What we really see is more trials being done in this space as well as more biological studies to refine the population who would benefit from earlier treatment. And this is what we’re going to see over the next five years. Clearly, the community is moving to treat and look at smoldering myeloma early, but they want to do it for the right patients and that’s where the work is concentrated in the next five years.
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