Prashant Kapoor, MD
Risk stratification for patients with newly diagnosed multiple myeloma is an essential component of the treatment plan, explains expert Prashant Kapoor, MD.
By using the revised International Myeloma Working Group (IMWG) criteria, physicians are able to determine if a patient has smoldering myeloma or active multiple myeloma, high-risk or standard-risk disease, and what molecular abnormalities they may harbor—which can be key to determining what treatments will garner responses, he adds.
Kapoor, assistant professor of medicine and of oncology, Mayo Clinic, discussed the various approaches for treating patients with newly diagnosed multiple myeloma in an interview during the 2017 OncLive®
State of the Science Summit on Hematologic Malignancies. In detail, he lectured on the importance of minimal residual disease (MRD) negativity, using IMWG criteria, and pivotal data that have truly changed the landscape.
OncLive: Your talk focused on the clinical approach for patients with newly diagnosed multiple myeloma. What did you highlight?
I started with the revised IMWG classification for multiple myeloma. These are in addition to the original CRAB criteria that we typically use to treat patients. Now, we have 3 additional criteria for starting therapy.
One of them is a patient with smoldering myeloma who has more than 60% plasma cells in the marrow, so extreme plasmacytosis is 1 criteria. The other 2 that have been added as myeloma-defining events are 1 focal lesion on the MRI, and involved versus uninvolved free light chain ratio of more than 100 typically in presence of at least 10 mg/dL of the involved free light chain.
These 3 additional criteria are new indications for treatment of myeloma. In essence, it’s the ultra high-risk patients with smoldering myeloma who have a risk of about 40% per year of transforming to active multiple myeloma—in whom we are now essentially asking clinicians to initiate therapy sooner than we typically did in the past.
One of the reasons for starting therapy sooner is, nowadays, the treatments are much better tolerated, and they have much better efficacy in contrast to the medications that we had available about a decade ago.
What are the first steps you take with a patient who has newly diagnosed disease?
When we see a patient in the clinic, 1 of the first steps we do is typically risk stratify patients with myeloma. We want to know whether these patients are high risk or standard risk. The vast majority of patients actually have standard-risk myeloma. The risk stratification is based on certain chromosomal abnormalities. It is important to risk stratify because it not only helps in prognosticating patients, but it also gives us an idea as to how we should treat and approach them, particularly the ones that are transplant eligible.
What is important to note about staging patients with myeloma?
I did talk about the IMWG, which has recently introduced a new staging system for risk stratification of myeloma. They have piggybacked on the original simple prognostic tool they used, and that was the International Staging System (ISS) introduced first in 2005. Now, more recently, they have integrated some of the cytogenetic abnormalities, in addition to LDH, and these biomarkers that we are now using are commonly used in the community. One can easily stage these patients and risk stratify them. They are not only very good prognostic tools, but we hope that in the future, we will be able to use these staging systems to guide our therapy, as well.
It is also important to emphasize one of the meta-analyses that was conducted very recently. There is a new response criteria that has been introduced by the IMWG, which is MRD-negative state, whether it is MRD state by a next-generation flow cytometry, or it is next-generation sequencing that we use to assess MRD. There is an MRD-imaging response criteria and that combines the PET scan with MRD, either by next-generation sequencing or next-generation flow cytometry.