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Smoldering vs. Active Myeloma: Is There a Difference in Treatment?

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Published on May 22, 2017

In this Patient Power replay, an expert panel discusses the differences in treatment between smoldering and active myeloma. The expert panel includes Host Andrew Schorr, Dr. Larry Anderson, Jr. of UT Southwest Medical Center, Dr. Robert Orlowski of MD Anderson Cancer Center, and patient advocate Lynette Heniff. In this video, the panel discusses risk features and progression of both smoldering and active myeloma and also why some myeloma patients may not need treatment at all.

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Transcript | Smoldering vs. Active Myeloma: Is There a Difference in Treatment?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you’ll get care that's most appropriate for you.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you. 

Dr. Anderson:

So the question is what’s the difference between smoldering and active—or the difference in the treatment… 

Andrew Schorr:

And the likelihood that it’s going to flip.

Dr. Anderson:    

And the risk of progression to symptomatic. So on average, it’s about 10 percent per year risk of progressing from smoldering to symptomatic myeloma. Certainly there are risk features that we look at to help determine if there’s a higher than 10 percent risk. One would be a monoclonal spike over 3 grams per deciliter.

One would be abnormal free light chains And then the other basically would be over 10 percent plasma cells. So if someone has all three of those, they’re going to be in a higher risk than average of progressing to symptomatic disease. And those patients definitely would want to consider going on a clinical trial. With active myeloma, that is they meet these newer criteria of having either 60 percent plasma cells or free light chain ratio over 100, or bone lesions on MRI that weren’t picked up on the skeletal survey; those patients I often tend to treat as regular symptomatic myeloma with the standard treatments that we would use for regular symptomatic myeloma.

Andrew Schorr:

But somebody with smoldering myeloma might have no treatment, right?

Dr. Anderson:    

Right. 

Dr. Orlowski:     

The standard right now would be no treatment. And as Larry mentioned, there are people within the smoldering category who can be classifiedeither at high, intermediate or low risk, and they’re very different. 

The low-risk patients are almost the same as MGUS, where the risk of progression is like 1 percent or 2 percent per year. And even in the high-risk group, the risk of progression is greatest in the first five years. If you make it to five years without progressing, the curve still goes up a little bit. but it’s much more shallow—meaning it’s not 10 percent per year every year—it’s only for the first five years. And after that, it’s more like 1 or 2 percent per year. So even with high risk, you don’t have 100 percent of patients progressing to symptomatic disease.

Dr. Anderson:    

And that’s why we hold off on treatment unless we really know they need it. After 20, 26 years of follow-up, a quarter of these patients may never have needed treatment for this myeloma. So why put them through the side effects of treatment, and maybe even make the resistant to treatment, before they even needed it or if they didn’t ever need it in the first place.

Andrew Schorr:

And your oath is do no harm, right?

Dr. Anderson:    

Right. 

Andrew Schorr:

Anything else you wanted to say? Were you going to comment on this?

Lynette Heniff: 

I was just going to say what Larry said, is that some of the side effects of these treatments can be intense and unpleasant. So if it’s appropriate not to have them, sometimes that is the right choice, even though you know you have a disease. Just continue to be followed. 

Andrew Schorr:

I was in watch-and-wait for my leukemia, chronic lymphocytic leukemia for four-and-a-half years. But the judgment was my situation was such that I didn’t need treatment yet, and the treatment would be sort of worse than the disease at that point. It’s an emotional load, right? You have smoldering myeloma. Myeloma is a cancer. Oh, my God. But you’ve got to go on with your life. And as you said, these are powerful treatments that can be very effective on the cancer as it progresses. But you don’t want to start that unless you need it. And some people may never.

Dr. Anderson:    

True, although what I think we’re trying to emphasize in the smoldering category when we do a clinical trial, we’re typically not throwing three or four drugs at them like we do in the symptomatic setting. We’re trying to do one drug or at most two drugs that are very targeted, because we’re trying to be very mindful of what you say. We don’t want to have people have horrible side effects and a horrible quality of life if they don’t necessarily absolutely need treatment. But the flip side is because their immune system may be healthier at that point, it may be the best opportunity to actually get rid of the myeloma.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.