Multiple Myeloma Management in 2021 - Episode 2

Role of Therapeutic Intervention in SMM

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Paul G. Richardson, MD: As we think about treatment approaches, David, what do you do, and what did you think of some of the data presented on actual therapeutic intervention?

David Siegel, MD, PhD: I would point out that I am much in the same camp as Nina. The notion that we need to make decisions about treatment the first time we meet a patient is contrary to my experiences with multiple myeloma [MM]. Certainly, understanding who is more likely to progress should drive how we monitor those patients.

However, until we have an intervention that is either with curative intent that seems to be more advantageous, such as when patients have lower burdens of disease, or we’re making an intervention that is specifically targeted at either the disease, specifically more or less likely the microenvironment of that disease, or some other host factor. I will acknowledge that the most interesting work that I’ve seen regarding this comes from your institution, Dana-Farber Cancer Institute, and that is Irene Ghobrial, MD’s work. Irene’s work has been published, and it is not just something presented at ASH [the American Society of Hematology annual meeting]. Irene’s work is very exciting because it was exhaustive evaluation that identified several variables that were host variables as much as disease-related variables that are also potentially targetable.

If early during the disease, before patients start to clearly identify themselves as, “This is just a patient with MM who we hadn’t identified yet.” Specifically, this is what the 2/20/20 [International Myeloma Working Group risk stratification model] is, to try to identify the people who genuinely have MM, who haven’t hit those markers yet. Irene’s work is exploring the biology in a much more comprehensive way. Until we have therapies that are directed at altering the milieu or very uniquely going to be effective, meaning curative, in those patients early on, I don’t see the compelling need to change our strategies. If I know a patient really has myeloma, then I’m going to treat them in the fashion I think is the best way to treat patients with myeloma. My approach is going to be different than your approach.

However, I don’t think that’s the take-home point for the community oncologist. The take-home point is you don’t need to decide about committing a patient to therapy just because you saw them for the first time.

Paul G. Richardson, MD: I agree.

David Siegel, MD, PhD: Patients who have MM are going to progress. If the next time you see the patient a couple of months later and the M spike has doubled, you can make that decision then. However, very rarely is something horrible going to happen in those first few months of monitoring.

Paul G. Richardson, MD: That’s an excellent point, David. I think that whole point about observation is exactly that—observation and monitoring is an integral part of risk assessment and getting that trajectory of disease is fundamental. I’m so grateful that you emphasized it, David.

Transcript Edited for Clarity