By Jerry Walton
Virginia Beach, VA
As always, the International Myeloma Foundation (IMF) did an absolutely super job arranging multiple myeloma (MM) support group leader (SGL) participation in this year’s 56th American Society of Hematology (ASH) annual meeting. Among the many key and helpful factors were: excellent preparatory info and organization by the IMF Senior Director of Support Groups Robin Tuohy; highlighting of the most important myeloma oral sessions and posters to focus on (out of 855!); providing access to key events involving myeloma experts; the helpful guidance provided by fellow support group leader and IMF Nurse Leadership Board member Teresa Miceli of Mayo Clinic; the multiple opportunities for SGLs to share information in discussion forums; and much more.
There was a lot of discussion at ASH of the International Myeloma Working Group’s (IMWG) recently updated criteria for the diagnosis of multiple myeloma. Smoldering multiple myeloma (SMM) is a biologically diverse disease, ranging from patients similar to those with monoclonal gammopathy of undetermined significance (MGUS) who progress to symptomatic myeloma at a very low rate, to patients who transition to symptomatic myeloma within 24 months of diagnosis. The IMWG definition of myeloma now includes one or more of the following biomarkers: clonal bone marrow plasma cell percentage of greater than or equal to 60%, involved/uninvolved serum free light chain ratio greater than or equal to 100, and greater than one focal lesion on MRI results.
A key poster at ASH showed the value of using PET-CT for evaluation of SMM. The conclusions were that patients with a positive PET-CT scan and underlying osteolysis (degeneration or dissolution of bone tissue) without therapy have a high risk (77%) of progression to MM within 2 years. The study states that their findings validate the recent IMWG recommendation that patients with a positive PET-CT and underlying osteolysis should be considered as active MM.
In the very informative Monday, December 8th IMWG Conference Series “Making Sense of Treatment” webcast, myeloma expert doctors Durie, Landgren, Palumbo, and Mikhael discussed High Risk SMM (HRSMM) and when to treat it. A key point they agreed upon is the need to define the “start line”: i.e., when to begin treatment. There was a general consensus to treat early, and to knock the disease down using the best possible induction therapy available. Dr. Landgren mentioned his clinical trial involving HRSMM patients given up front carfilzomib/Revlimid/dexamethasone (CRD). 12 out of 12 achieved the complete response (CR) category after five cycles. He mentioned the importance of key measures to determine CR and Minimum Residual Disease (MRD); e.g., PET/CT imagery, flow cytometry, and the next generation sequencing genetic test. When asked to choose from a list of clinical trial types they would recommend for further studies on treatment of HRSMM, the doctors chose the trial involving the combination triplet CRD. A daratumumab trial was their second choice.
Dr. Durie asked the doctors whether they recommended an autologous stem cell transplant (ASCT) for eligible patients with MM. Dr. Mikhael mentioned data from multiple trials that indicate ASCTs remain an effective, important tool, increasing progression free survival (PFS) and overall survival (OS). Dr. Palumbo strongly supported ASCT, saying that the data without a doubt support ASCT up front by increasing PFS and OS, and that we do not yet have a drug to overcome the value of early ASCT. Perhaps new drugs will, he said; but to evaluate those new drugs, we need a better definition of response. Dr. Landgren said that this is a hot topic in MM, and that emerging new drugs can provide a better response than oral drugs with a transplant. He cited a situation where all patients achieved MRD negative, adding that if that’s the case, what would an ASCT add? His answer: we don’t know yet; relevant studies are ongoing. He does recommend ASCT now but cited the need for more data regarding effectiveness of new drugs. In summary, all three recommend ASCT, until clinical trial data shows equivalent or better responses with novel therapies.
The doctors also discussed the need to consider modifying the number of induction cycles based on patient response. Using a fixed number of induction cycles results in some patients having residual disease and who therefore will benefit from an ASCT. However, if MRD is used to monitor induction results and more treatment cycles are given until MRD negative is achieved, it’s possible that the patient could achieve the equivalent result of an ASCT.
A lot more ASH 2014 myeloma topics of interest are discussed in the December 8th webcast. Additionally, key highlights of ASH will be provided in Dr. Durie’s comprehensive Best of ASH 2014 telecast on Thursday, Jan 15, at 7p.m. EST. You can sign up for it here. IMF ASH videos including the Dec. 8th webcast are accessible at the IMF website www.myeloma.org under “IMF TV” and then “webcasts from medical meetings“.
Thank you, IMF, for another great ASH experience for support group leaders, and for your renowned success in helping to educate patients, caregivers and support groups. In addition, thank you for your key leadership role in bringing together myeloma experts worldwide through the IMWG and other forums, leading them down the path to an ultimate cure.