Experts Discuss New Diagnostic and Management Approaches in Multiple Myeloma

By Sara Thier, PhD, MPH
Published: Wednesday, Feb 11, 2015

Treatment of Multiple Myeloma


A. Keith Stewart, MB ChB
Professor Dean for Research Mayo Clinic Scottsdale, AZ


James R. Berenson, MD
Medical & Scientific Director Institute for Myeloma and Bone Cancer Research Los Angeles, CA

Sundar Jagannath, MD
Director, Multiple Myeloma Research Program Professor, Medicine The Tisch Cancer Institute Mount Sinai Medical Center New York, NY

Shaji K. Kumar, MD
Professor, Medicine Mayo Clinic Rochester, MN

Sagar Lonial, MD
Professor Vice Chair, Clinical Affairs Department of Hematology & Medical Oncology Winship Cancer Institute Emory University School of Medicine Atlanta, GA

Jeffrey A. Zonder, MD
Associate Professor, Medicine Barbara Ann Karmanos Cancer Institute Wayne State University Detroit, MI
Keith K. Stewart, MD

A. Keith Stewart, MBChB

With the advent of safer and more effective treatments, early diagnosis of multiple myeloma (MM) has become an important goal. Recent data show that early intervention in high-risk smoldering MM can prolong survival, according to experts who participated in a recent OncLive Peer Exchange program. Led by the moderator, A. Keith Stewart, MB ChB, a panel of clinical and research experts discussed the evolving treatment of MM, including upfront approaches, managing patients with relapsed and refractory myeloma, and emerging regimens during a Peer Exchange session entitled “Treatment of Multiple Myeloma.”

Redefining Active Multiple Myeloma

Sagar Lonial, MD, described the new diagnostic criteria developed by the International Myeloma Working Group to help define symptomatic myeloma (Table 1).1 These changes include: 1) the presence of >1 focal bone lesion by MRI or PET scan; 2) free light chain ratio ≥100; and 3) ≥60% plasma cells in the bone marrow. These additions are based on the identification of biomarkers associated with near-inevitable development of CRAB features (hypercalcemia, renal failure, anemia, and bone lesions) in patients who would otherwise be regarded as having smoldering multiple myeloma. Delaying diagnosis and treatment in these active MM patients could be harmful and result in poor outcomes.

Pretransplant Regimens: Two or Three Agents?

James R. Berenson, MD

James R. Berenson, MD

James R. Berenson, MD, and Lonial agreed that optimal treatment of MM incorporates the administration of three medications, rather than two, in most transplant-eligible patients. Sundar Jagannath, MD, stated that clinical trials, including large international studies (FIRST, UPFRONT2,3), have demonstrated efficacy with two-medication regimens, such as lenalidomide and dexamethasone, and bortezomib- based regimens.

On this basis, Jagannath stated that it is difficult to only recommend the use of three medications. In his practice, he explained, they administer bortezomib, lenalidomide, and dexamethasone, noting that giving a proteasome inhibitor, an immunomodulatory agent, and a steroid is important, as MM has numerous clones and physicians should cover most of the clones in newly diagnosed individuals.

Examining Transplant and Maintenance Therapy

Jeffrey A. Zonder, MD, explained that stem cell transplant in patients with MM deepens response in the subset of patients who have not achieved complete response on therapy prior to transplant. Studies have demonstrated that pretransplant individuals in apparent complete remission, but not minimum residual disease (MRD)–negative, become MRD–negative after transplant, noted Zonder. Lonial added that achieving complete remission is “only the middle of the iceberg.”

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