Should smoldering myeloma patients start treatment?

What to do when a patient's smoldering myeloma is borderline high-risk?

In this episode, Dr. Brian G.M. Durie discusses when smoldering myeloma patients should begin treatment and how to know if you are at high risk of progressing to active myeloma.


Monitor your levels closely with your doctor. Do not begin treatment until there is evidence that the disease is high-risk smoldering myeloma or if it has progressed to active myeloma.

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This week’s “Ask Dr. Durie” is again a very common question. It comes from a patient with smoldering myeloma who wants to know: Should they start treatment? What that means is, they want to know if they have what’s called “high-risk” smoldering myeloma, where the risk of turning into active myeloma is high within the next year to year and a half, or so. 

The problem arises because that high-risk definition is based upon three test results right now. The level of the myeloma protein in the blood, if it’s 2 grams or higher, the percentage of myeloma cells in the bone marrow if it’s 20-percent or higher, and the Freelight ratio if it’s 20 or higher.   

The problem, for example, for this patient is that the numbers have been fluctuating around these different levels. And so, it’s been hard to know maybe one test result when the results are above the 2/20/20, and next time they’re not.   

My strong recommendation in this situation is to wait and to continue to monitor. If these numbers are fluctuating, then this is not a good situation to be decisively moving forward with therapy. It’s better to wait, re-check, all and see if the numbers are going up month upon month, or every three months possibly if things are changing very slowly. The first recommendation is definitely to wait. 

The second point is that of the various tests that we have, the percentage of plasma cells in the bone marrow is perhaps the most indicative of a higher risk of progression. If the percentage of plasma cells in the bone marrow is increasing from 20-percent to 30-percent, up to 40-percent, this is something to pay attention to in terms of risk. 

This is often reflected by a change in the whole-body PET/CT scan. In other words, if the percentage of plasma cells is going up, then this is often reflected by maybe a new lesion showing up on an MRI or a PET/CT scan.  

These are significant tests and so, periodically at a three-to-six-month interval would be reasonable to consider checking those kinds of things.   

The BOTTOM LINE here is: Please hold off on treatment until there’s a clear indication that you have crossed that threshold and there is a need for active treatment. Sometimes there can be fluctuations that continue for many months to years without the need for active intervention. So, wait and be sure, and monitor closely.   

Image of Dr. Brian G.M. DurieDr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.


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