Are treatment options available for patients with smoldering myeloma?

This week's "Ask Dr. Durie" comes from a patient anxious to know whether she should start treatment or not. This particular lady has been told that she has smoldering myeloma. 

And so, starting to ask questions is an excellent idea. There are different types of smoldering myeloma and it is very important to talk to your doctor about where you fall in the spectrum of disease from very low risk to perhaps higher risk, and motoring where some sort of treatment may be recommended.

The risk system that we use right now is called the 2/20/20 system. This is based on the level of the myeloma protein in the blood—two grams or greater, the free light ratio—20 or greater, and the percentage of plasma cells in the bone marrow—20 or greater. 

Now on the high-end of the scale, a patient may be considered to have high risk. On the lower end of the scale, low risk. And so, obviously, the first decision is if you fall into that lower risk category. With low-level numbers, observation is recommended—strongly recommended versus considering any therapy because the risk of progressing to active myeloma within the next year or two is low. 

This is the first major step. If the numbers are a bit higher, then this is where it's important to look more closely. There is a new testing option developed by the Spanish team in Pamplona which indicates if you have plasma cells in the blood, which can be detected using a new flow blood test, then this can indicate active disease. And so, this could be an indicator that maybe some consideration for treatment is the best. 

Now, is there an option for treatment for high-risk smoldering myeloma? Right now, there is not a definitive answer as to which treatment is best. There can be a simple treatment using lenalidomide, which is Revlimid. Use that alone by mouth to reduce the risk of progression, and some good results have been seen with that, or to consider more myeloma-like treatment, using something like VRd or even more aggressive treatment to decisively treat the smoldering myeloma and perhaps even to achieve cure. 

We have a couple of trials, the CESAR trial, and the ASCENT trial, which have been evaluating this with quite good results. 

However, the BOTTOM LINE right now is: If you have low-risk disease, it's very important to observe and monitor closely for now. If the numbers indicate evidence of progression or high-risk disease status, you need to talk very closely with your doctor and maybe even get a second opinion or expert consultant to see if treatment is recommended, and if so, whether simply lenalidomide or maybe something more aggressive even within a clinical trial could be suitable for you.