ADVERTISEMENT

Treatment and Management of Multiple Myeloma

A panel discussion of the challenges and standards of care for managing patients with multiple myeloma.
Federal Practitioner. 2017 February;34(1)s:
February 17, 2018|Federal Practitioner
João Ascensão, MD, PhD;Thomas R. Chauncey, PhD;Sean P. Cosgriff, PharmD, BCOP;Paulette Mehta, MD, MPH
Author and Disclosure Information

Moderator
João Ascensão, MD, PhD, is a professor in the Department of Medicine and Immunology at George Washington University School of Medicine and chief hematologist and chairman of the R&D Committee at the Washington DC VA Medical Center, both in Washington, DC. He is also a clinical professor of medicine at Uniformed Services University in Bethesda, Maryland. In 2015 Dr. Ascensão served as president of the Association of VA Hematology/Oncology (AVAHO).

Panelists
Thomas R. Chauncey, MD, PhD, is an associate professor of medicine and oncology at the University of Washington, and an associate member of the Fred Hutchinson Cancer Research Center. Dr. Chauncey is director of the Marrow Transplant Unit at the VA Puget Sound Health Care System, all in Seattle.

Sean Cosgriff, PharmD, BCOP, is the hematology/oncology clinical specialist at the VA Portland Health Care System and affiliate faculty at Oregon State and Pacific University, both in Portland, Oregon. In 2014 Dr. Cosgriff served as AVAHO president.

Paulette Mehta, MD, MPH, is a professor of hematology/oncology at the University of Arkansas and a physician at the Central Arkansas Veterans Healthcare System, both in Little Rock. In 2010, Dr. Mehta served as AVAHO president.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

 

The following is a lightly edited transcript of a follow-up teleconference discussion on treating patients with multiple myeloma in the VHA. For more information and the original conversation, visit FedPrac.com/AVAHOupdates.

Early Treatment and Diagnosis

Dr. Ascensão. An area that is becoming very important is identifying and separating smoldering multiple myeloma (SMM) from multiple myeloma (MM) and determining when to start treatment. At the Washington DC VAMC (DCVAMC) we started early on bisphosphonates and thalidomide without much benefit, but perhaps we were treating the wrong disease.

Dr. Mehta. Identifying patients as early as possible is often the best way to start. Treating early disease is easier than treating late disease, and it avoids all the complications. The problem is we don’t want to treat too many people because some of the people with SMM will never develop overt MM and, therefore, may not need treatment. We don’t have benign treatment yet. Whatever treatment we decide to use is going to carry adverse effects and toxicity.

So the trick is identifying those patients with SMM who are likely to progress in a finite period and, therefore, can be helped by treating early to avoid the complications of late diagnosis. We know that early treatment for patients with high-risk SMM helps. In a report from Lancet Oncology, early treatment with lenalidomide and dexamethasone reduces time to progression.1 There are other reports that treating early reduces time to progression.

So how do we identify those patients who are going to progress? We have a few clues. We know that patients who have a myeloma spike of > 1.5 g/dL are more likely to progress than others…The more discordant the / ratio from 1:1, the higher the risk for progression. And if that ratio is 1:100 or more, that would be a risk factor for progression.

We know from the work of Mayo Clinic researchers that if there are ≥ 60% of plasma cells in the bone marrow then it is a risk factor for progression. And we know from early studies that magnetic resonance imaging (MRI) detection of bone lesions, even long before they become detectable by X-ray, also is a risk factor for rapid development to myeloma.

...Methods such as genotyping, which we do here at the University of Arkansas for Medical Sciences, even in patients with MGUS (monoclonal gammopathy of undetermined significance), can identify high-risk patients, but that is not the standard of care yet. But it may become the standard of care in the days to come.

Another thing to think about for MGUS patients: Are there ways to identify what causes MGUS patients to evolve to SMM and then to overt myeloma, and to develop means of interrupting the progression cascade? There have been clinical trials on treatments (eg, bisphosphonates, thalidomide, aspirin, and cyclooxygenase inhibitors), but we haven’t found any safe, good treatment to prevent progression yet. With better technologies, we may be able to do that.

Dr. Ascensão. At the DCVAMC often we receive consults for a patient who had a little anemia, diabetes, renal disease, and the serum protein electrophoresis reveals a very small peak. How often should you follow patients? Do you do a complete workup the moment you see an MGUS or do you wait until they reach SMM?

Dr. Mehta. I don’t think every patient needs a complete workup. If you have obviously identifiable reasons for the anemia or the renal failure, then it’s less likely to be suspicious for myeloma. But patients with M spikes > 1 g/dL deserve a workup with a bone marrow aspirate and biopsy and at least bone X-rays, although MRIs would be even better.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT