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Mohyuddin GR, Chakraborty R, Cliff ERS, Derman BA. Clinician preferences on treatment of smoldering myeloma: a cross-sectional survey. EClinicalMedicine 2023; 65:102272. [PMID: 38046471 PMCID: PMC10689285 DOI: 10.1016/j.eclinm.2023.102272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 12/05/2023] Open
Abstract
Background Smoldering myeloma (SMM) is an asymptomatic precursor condition to multiple myeloma (MM) with a variable risk of progression. The management of high-risk SMM (HR-SMM) remains controversial, particularly with changes in diagnostic criteria that led to reclassifying of some patients with SMM to MM. This study aimed to assess clinician preferences for whether to treat patients with HR-SMM and/or patients with MM diagnosed solely by SLiM criteria (free light chain ratio >100, bone marrow plasma cell percentage >60, greater than two focal marrow lesions on MRI) through an electronic survey. Methods This was a cross-sectional survey of clinicians, conducted via an anonymous online REDCap survey from May 16th to July 5th, 2023. The survey included questions on demographics, SMM surveillance practices, and management preferences for two clinical scenarios (HR-SMM and MM based solely on the free light chain ratio >100 criterion). Data was analysed descriptively via Microsoft Excel. Findings A total of 146 clinicians completed the full survey, with 92% recommending against routine treatment for a patient with HR-SMM based on a single time point assessment, instead preferring active surveillance. For patients with MM diagnosed solely on the basis of a free light chain ratio >100, 61% recommended active treatment, while 37% recommended active surveillance. The most common reasons recommending against treatment of HR-SMM were toxicity, lack of demonstrated overall survival benefit, and low MM-defining event rates in clinical trials. Interpretation The survey indicates that most clinicians recommend against routine treatment for HR-SMM. Active surveillance is the prevailing standard of care and it is therefore an appropriate control arm in future SMM trials. More randomised trials are needed to determine if early treatment of modern-era SMM offers a net benefit to patients. Funding None.
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Affiliation(s)
| | - Rajshekhar Chakraborty
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, USA
| | - Edward R. Scheffer Cliff
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, USA
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Chakraborty R, Al Hadidi S, Scheffer Cliff ER, Mohyuddin GR. Is aggressive treatment of smoldering myeloma the path to curing myeloma? Blood Adv 2023; 7:3932-3935. [PMID: 37196639 PMCID: PMC10405196 DOI: 10.1182/bloodadvances.2023009658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/19/2023] Open
Affiliation(s)
- Rajshekhar Chakraborty
- Multiple Myeloma and Amyloidosis Program, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Samer Al Hadidi
- Myeloma Section, Winthrop P. Rockefeller Cancer Institute at the University of Arkansas for Medical Sciences, Little Rock, AR
| | - Edward R. Scheffer Cliff
- Program on Regulation, Therapeutics and Law, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Thorsteinsdóttir S, Gíslason GK, Aspelund T, Rögnvaldsson S, Óskarsson JÞ, Sigurðardóttir GÁ, Þórðardóttir ÁR, Viðarsson B, Önundarson PT, Agnarsson BA, Sigurðardóttir M, Þorsteinsdóttir I, Ólafsson Í, Eyþórsson E, Jónsson Á, Berlanga O, Hultcrantz M, Durie BGM, Löve TJ, Harding S, Landgren O, Kristinsson SY. Prevalence of smoldering multiple myeloma based on nationwide screening. Nat Med 2023; 29:467-472. [PMID: 36747117 PMCID: PMC11099842 DOI: 10.1038/s41591-022-02183-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/13/2022] [Indexed: 02/08/2023]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic precursor to multiple myeloma. Here we define the epidemiological characteristics of SMM in the general population in Iceland. The iStopMM study (ClinicalTrials.gov ID: NCT03327597 ) is a nationwide screening study for multiple myeloma precursors where all residents in Iceland 40 years or older were invited to participate. SMM was defined as 10-60% bone marrow plasma cells and/or monoclonal (M) protein concentration ≥3 g dl-1, in the absence of myeloma-defining events. Of the 80,759 who gave informed consent to participate, 75,422 (93%) were screened. The prevalence of SMM in the total population was 0.53% (95% confidence interval (CI) = 0.49-0.57%) in individuals 40 years or older. In men and women, the prevalence of SMM was 0.67% (95% CI = 0.62-0.73%) and 0.39% (95% CI = 0.35-0.43%), respectively; it increased with age in both sexes. For the 193 individuals with SMM, median age was 70 years (range 44-92 years) and 60% were males. The mean M protein concentration of individuals with SMM was 0.62 g dl-1 (range 0.01-3.5 g dl-1) and 73% had 11-20% bone marrow plasma cell infiltration. The high prevalence of SMM has implications for future treatment policies in multiple myeloma as the evidence supporting treatment initiation at the SMM stage is emerging.
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Affiliation(s)
- Sigrún Thorsteinsdóttir
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | | | - Thor Aspelund
- Public Health Sciences, University of Iceland, Reykjavík, Iceland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Brian G M Durie
- Cedars-Sinai Samual Oschin Cancer Center, Los Angeles, CA, USA
| | | | | | - Ola Landgren
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Sigurður Y Kristinsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland.
- Landspítali University Hospital, Reykjavík, Iceland.
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Thorsteinsdottir S. The consultant's guide to smoldering multiple myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:551-559. [PMID: 36485144 PMCID: PMC9821526 DOI: 10.1182/hematology.2022000355] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic precursor condition to multiple myeloma (MM). The prevalence of SMM is 0.5% in persons over 40 years old; it is higher in men than women and increases with age. When SMM is diagnosed, a thorough diagnostic workup is necessary to exclude myeloma-defining events and stratify patients according to risk of progression to MM. While close monitoring for progression remains the best management for most patients with SMM, in this article, we discuss if treatment initiation before myeloma-defining events occur might be relevant in selected high-risk cases. Two randomized clinical trials have shown a clinical benefit of initiating treatment at the SMM stage, whereof 1 showed an overall survival benefit for those receiving treatment. We discuss various risk stratification models in SMM, important treatment trials, and ongoing trials. Finally, we present how to approach the clinical management of patients with SMM.
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Affiliation(s)
- Sigrun Thorsteinsdottir
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
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Survival in smouldering myeloma and symptomatic myeloma: Is there an emerging Will Rogers phenomenon? Eur J Cancer 2022; 172:234-236. [DOI: 10.1016/j.ejca.2022.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/16/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022]
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Gertz M. Smoldering multiple myeloma: Reviewing the rationale for intervention. Leuk Lymphoma 2022; 63:2033-2040. [PMID: 35532298 PMCID: PMC9719610 DOI: 10.1080/10428194.2022.2068008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/05/2022] [Accepted: 04/09/2022] [Indexed: 10/18/2022]
Abstract
Smoldering multiple myeloma has been recognized for over 40 years and represents a pre-symptomatic phase of the 2nd most common hematologic malignancy. 1/3 of patients will remain asymptomatic at 10 years. There is an identifiable subset of patients that will develop CRAB within 2 years of recognition and these patients are considered for therapeutic intervention before the development of potentially irreversible complications. Obstacles to widespread implementation of therapeutic guidelines are limited by the variable definitions associated with this high-risk group as well as the poor concordance between classification schemes. Analysis of clinical trial outcomes as well as uniform eligibility helps determine whether a given patient should be considered for therapeutic intervention outside of a clinical trial.
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Affiliation(s)
- Morie Gertz
- Mayo Clinic Rochester Minnesota, Rochester, USA
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Vaxman I, Gertz MA. How I approach smoldering multiple myeloma. Blood 2022; 140:828-838. [PMID: 35576526 PMCID: PMC9412010 DOI: 10.1182/blood.2021011670] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/28/2022] [Indexed: 11/30/2022] Open
Abstract
The current standard of care in smoldering multiple myeloma (SMM) is close surveillance, outside of clinical trials. Efforts are being made to understand the pathobiologic process that leads to the progression of SMM to active MM. This review provides a critical description of available data, including risk factors and risk models of progression, as well as clinical trials investigating interventions for this patient population. We describe 2 cases in which patients were seen before the concept of a myeloma-defining event was established. Today, based on the International Myeloma Working Group criteria, both patients would have been identified as experiencing myeloma-defining events, and therapy would have been initiated. These cases show that occasionally, patients can undergo observation only, even when they exceed criteria for high-risk SMM.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; and
- Department of Hematology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Soomro MA, Hoffman J, Goodman AM, Sborov DW, Mohyuddin GR. Heterogeneity of enrolment criteria for ongoing smouldering myeloma trials. Br J Haematol 2022; 197:e86-e88. [PMID: 35229286 DOI: 10.1111/bjh.18102] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/30/2022] [Accepted: 02/09/2022] [Indexed: 01/03/2023]
Affiliation(s)
| | - James Hoffman
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Coral Gables, Florida, USA
| | - Aaron Michael Goodman
- Division of Blood and Marrow Transplantation, University of California San Diego, San Diego, California, USA
| | - Douglas Weston Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
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Management of Adverse Events and Supportive Therapy in Relapsed/Refractory Multiple Myeloma. Cancers (Basel) 2021; 13:cancers13194978. [PMID: 34638462 PMCID: PMC8508369 DOI: 10.3390/cancers13194978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Multiple myeloma (MM) patients with relapsing and/or refractory (RR) disease are exposed for a prolonged time to multiple drugs, which increase the risk of toxicity. In addition to tumor response, preserving the quality of life represents an important goal for this patient population. Therefore, supportive therapy plays a pivotal role in their treatment by limiting disease- and drug-related complications. The aim of this review is to outline current standards and future strategies to prevent and treat renal insufficiency, anemia, bone disease, and infection, including COVID-19, in RRMM patients. In addition, the incidence and treatment of side effects of novel anti-MM agents will be discussed. Abstract Relapsed/refractory (RR) multiple myeloma (MM) patients are a fragile population because of prolonged drug exposure and advanced age. Preserving a good quality of life is of high priority for these patients and the treatment of disease- and treatment-related complications plays a key role in their management. By preventing and limiting MM-induced complications, supportive care improves patients’ outcome. Erythropoietin-stimulating agents and bisphosphonates are well-established supportive strategies, yet novel agents are under investigation, such as anabolic bone agents and activin receptor-like kinase (ALK) inhibitors. The recent dramatic changes in the treatment landscape of MM pose an additional challenge for the routine care of RRMM patients. Multidrug combinations in first and later lines increase the risk for long-lasting toxicities, including adverse cardiovascular and neurological events. Moreover, recently approved first-in-class drugs have unique side-effect profiles, such as ocular toxicity of belantamab mafodotin or gastrointestinal toxicity of selinexor. This review discusses current standards in supportive treatment of RRMM patients, including recommendations in light of the recent SARS-CoV-19 pandemic, and critically looks at the incidence and management of side effects of standard as well as next generation anti-MM agents.
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Gertz MA, Vaxman I. Should high risk smoldering myeloma be treated outside a clinical trial: NO. Leuk Lymphoma 2021; 62:2565-2567. [PMID: 34261405 DOI: 10.1080/10428194.2021.1951723] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center Petah- Tikvah, Petah Tikva, Israel.,Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
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