A recent article in The New England Journal of Medicine has provoked conversation about the management of smoldering multiple myeloma.1 At the recent National Comprehensive Cancer Network (NCCN) Annual Conference, Kenneth C. Anderson, MD, of Dana-Farber Cancer Institute, Boston, shared his thoughts on the topic with The ASCO Post.
He noted that smoldering myeloma was first described around 1980 as patients with plasmacytosis and monoclonal protein in lesser amounts, lacking clinical features. “These patients could go 8 to 10 years without treatment,” he pointed out. “Now, we can define a population who are more at risk and who progress to active myeloma more quickly.” These so-called “high risk” patients are being enrolled in trials evaluating “high-risk protocols,” he said.
Redefining Smoldering Myeloma
In the study by Mateos et al, lenalidomide/dexamethasone prolonged progression-free survival and overall survival in a “high-risk” population. However, Dr. Anderson and other experts have questioned whether the population was 100% “smoldering.”
“If they truly had smoldering myeloma, why is there a survival advantage already, early on in the trial? It tells us that some of those patients who were thought to have smoldering myeloma actually had active myeloma, and their outcome was poorer than usual,” he suggested.
The International Myeloma Working Group is currently redefining smoldering myeloma. “The likelihood is that smoldering myeloma will become a smaller group of patients, and the active myeloma group will become larger,” he said. Meanwhile, Dr. Anderson’s opinion is that smoldering myeloma patients should be enrolled in clinical trials but should not receive treatment off-protocol. ■
Disclosure: Dr. Anderson is on advisory boards for Celgene, Millennium, Onyx, Gilead, and Sanofi Aventis. He is Scientific Founder of Acetylon and Oncopep.
1. Mateos MV, Hernandez MT, Giraldo P, et al: Lenalidomide plus dexamethasone for high-risk smoldering multiple myeloma. N Engl J Med 369:438-447, 2013.