Published on March 29, 2018
What kind of treatment do smoldering myeloma patients require? Can early intervention make a difference in prognosis? Our panel of dedicated myeloma researchers, including Dr. Carol Ann Huff, Dr. Sagar Lonial and Dr. Suzanne Lentzsch, describe the treatment approach for high-risk and low-risk smolders, and discuss the long-term effects on quality of life, longevity and disease development. Tune in to hear what the latest research shows on treatment methods for smoldering myeloma patients.
Produced by Patient Power. We thank you to thank AbbVie, Inc., Celgene and Takeda Oncology for their support.
Transcript | How Aggressive Should Smoldering Myeloma Treatment Be?
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In smoldering myeloma, it seems like there’s an approach, especially for high-risk smolders, to achieve a cure. Dr. Lentzsch, do you want to speak to the research that you’ve seen about smoldering myeloma in general, or high-risk smoldering?
So there are many studies ongoing in smoldering myeloma with a relatively aggressive approach; that means with quadruplet, so KRD, for instance, and daratumumab (Darzalex), RVD and daratumumab. I think we need to wait for the data. Treatment of high-risk smoldering myeloma is for sure probably the future, that we treat patients earlier and earlier. We don’t wait to wait until you have anemia, hypercalcemia, or renal damage. I think the concept of treating the disease at a time you have no organ damage and you prevent organ damage makes absolutely sense, and I think it’s urgently needed.
The question is, how aggressive should we be in smoldering myeloma? Should we move toward transplant, for instance? I think those questions are right now very open. But I personally appreciate the concept of treating patients much earlier.
I would agree. We also saw data at ASH this year looking at the concept of using daratumumab in intermediate or high-risk smoldering myeloma, which will be expanded into a Phase III trial looking at standard dosing of daratumumab or close to standard dosing; weekly followed by bi-weekly, and then ultimately extending out to bi-monthly dosing. But really looking at achieving remissions in smoldering myeloma based on standard response criteria, and so I think that really what that regimen and exactly what the long-term benefits are remain to be determined.
But I think we’re all very much in favor, if we are able to treat patients prior to them becoming symptomatic and improving their longevity, as well as their quality of life, we’re all supportive of that.
And so in a clinical trial also, right?
I noticed the clinical trials that had KRD, a transplant, KRD afterwards, and then lenalidomide (Revlimid) and dexamethasone (Decadron) on the end, so for a smoldering patient, you’ve always thought, well, watch and wait, or treat? Do you have any comments about that?
Yeah. So I think of those as proof of concept trials, and I think doing that as a proof of concept is a really reasonable, fair thing to do. It is, by no means, standard of care. And I think—to be honest with you, I think the first thing we have to prove is that intervening in a smoldering patient makes a difference. And many would argue that the Spanish trial from a few years ago of Rev/dex versus observation proved that point.
I actually don’t agree with that. I don’t think that that proved that point that intervening makes a difference because that trial didn’t use advanced imaging. Many of those patients had bone disease or had other things that we would, in this country, already have called myeloma.
And so I think that underlying question still remains. If intervening early does make a difference, then going to that kind of an aggressive triplet induction, transplant, maintenance, just like you do a myeloma patient, makes perfect sense. But I think we’re missing one key piece of information, which is in a randomized trial, does intervening early make a difference? And the response rate is not the right endpoint. It’s really a long-term, 10-year endpoint that really makes a difference because this—smoldering patients can stay smoldering for a long time and don’t have all the side effects of treatment that we’re giving them with early therapy.
Yes, and patients have to be careful not to make the mistake to say, “Oh, I have smoldering myeloma, and I need treatment right away.” I think the question needs to be answered in randomized trials.
Yeah. Because I think the concern is, if prostate cancer had been as smart as Dr. Kyle was 30 years ago and had not called anybody with anything prostate cancer, but had done what Dr. Kyle did and create MGUS and smoldering, all these patients that have “prostate cancer” that will never develop anything related to cancer that are being treated with aggressive therapy could have been saved all that treatment. I’m excited about it. I led a large smoldering trial that’s a randomized trial. But I want to see the data from that before I make routine recommendations for care.