Management of asymptomatic myeloma patients

Abstract

Smoldering multiple myeloma is an asymptomatic disorder characterized by the presence of ≥30 g/l serum M-protein and/or ≥10% bone marrow plasma cell infiltration. The risk of progression to active multiple myeloma is not uniform, and several markers are useful for identifying patients at high risk of this. Although the current standard of care is not to treat, a randomized trial in high-risk smoldering multiple myeloma patients comparing those allocated to receive early treatment with lenalidomide plus dexamethasone with those under observation reported a significant benefit with respect to time to progression and overall survival. We conclude that efforts should be made to identify high-risk patients who are candidates for receiving early treatment before they develop myeloma-related symptomatology.

Keywords:

• asymptomatic myeloma
• early treatment
• lenalidomide
• risk factor
• smoldering

Financial & competing interests disclosure

MV Mateos has received payment from Celgene for lectures. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Smoldering multiple myeloma is not a homogeneous plasma cell disorder, and includes patients at low, intermediate and high risk of progression to symptomatic myeloma.

• All newly diagnosed smoldering multiple myeloma patients should be stratified according to their risk.

• It is essential to identify patients at high risk of progression to symptomatic disease, in which the progression risk is 50% at 2 years following diagnosis, and those at ultra-high risk, who have an 80–90% probability of progression at 2 years following diagnosis.

• Although the standard of care has been no treatment until symptomatology occurs, early treatment with lenalidomide plus dexamethasone has helped change the treatment paradigm for high-risk smoldering patients.

• According to the revisited, but as yet unpublished International Myeloma Working Group criteria, smoldering myeloma patients at ultra-high risk of progression will start systemic therapy as symptomatic multiple myeloma patients.

• In the future, novel therapeutic approaches will determine whether early treatment of asymptomatic high-risk patients is able to definitively prevent the development of myeloma-related symptomatology.