Jeffrey Wolf, MD, clinical professor, Department of Medicine, director, Myeloma Program, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, discusses high-risk multiple myeloma.

The origin of the name multiple myeloma came from the multiple lytic lesions. In recent years, the name has shortened to myeloma, but Wolf says that it is time to change it back, because it signifies that there are different types of myeloma. Patients with standard-risk multiple myeloma usually have a very good prognosis, with some living for 20 years with their cancer. Conversely, there is a high-risk pattern that affects about 20% to 25% of patients who rarely live past 2 years, says Wolf.

These high-risk patients can be identified by fluorescence in situ hybridization (FISH) or by doing gene expression profiling. Wolf says that identifying this population is important because it can guide treatment decision. There are early data suggesting that maintenance therapy after an autologous stem cell transplant can make a difference in these patients. Additionally, using multiple agents may be more effective than using 1, and potentially change their risk from high to standard, Wolf explains.

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Dr. Wolf Discusses High-Risk Multiple Myeloma

Jeffrey Wolf, MD, clinical professor, Department of Medicine, director, Myeloma Program, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, discusses the treatment approach for patients with high-risk multiple myeloma.

Early evidence suggests that maintenance therapy after autologous stem cell transplant makes a difference, especially in high-risk patients. Using lenalidomide (Revlimid), bortezomib (Velcade), and dexamethasone for several years may convert high-risk patients to standard-risk patients. That has been reflected in the new staging system.

The International Staging System used albumin and beta-2 microglobulin to identify who was stage III or high risk. Physicians now require an elevated beta-2 microglobulin as well as either an elevated lactic acid dehydrogenase or 1 of the several abnormal fluorescence in situ hybridization tests that predict for high risk. This would be 17p deletion, t(4;14) or t(14;16). The revised International Staging System seems to better predict for high risk than the original International Staging System.

Dr. Wolf on the Treatment of High-Risk Patients With Multiple Myeloma

Jeffrey Wolf, MD, clinical professor, Department of Medicine, director, Myeloma Program, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, discusses treatment options for patients with multiple myeloma.

Wolf says that in the rapidly evolving space of multiple myeloma, the use of initial triplet therapies should be emphasized for patients with newly diagnosed disease. For example, patients with renal involvement may recieve the triplet of cyclophosphamide with bortezomib (Velcade) and dexamethasone. Those with renal failure are often admitted for high-dose cyclophosphamide, high-dose dexamethasone, and a proteasome inhibitor. A plasma exchange is sometimes done as well in these patients, Wolf adds.

Patients who present with multiple myeloma who do not have high-risk disease are often given an immunomodulatory triplet such as lenalidomide (Revlimid) with bortezomib and dexamethasone. This regimen can be given to patients of all ages, regardless of transplant eligibility, says Wolf. However, doses are adjusted by age and frailty.

Dr. Wolf Discusses Treatment Options for Multiple Myeloma

Jeffrey Wolf, MD, clinical professor, Department of Medicine, director, Myeloma Program, University of California, San Francisco Helen Diller Family Comprehensive Cancer Center, details the role maintenance therapy has in treating patients with myeloma.

Wolf explains that the CALGB 100104 and the French IFM studies demonstrate the role maintenance therapy has in improving progression-free survival (PFS) in patients, including those with high-risk disease. In the CALGB 100104 study, lenalidomide (Revlimid) versus placebo after autologous stem cell transplantation was investigated in patients with newly diagnosed myeloma. In the French IFM study, the role of lenalidomide maintenance was also tested until relapse in patients under 65 treated with a vincristine/doxorubicin/dexamethasone regimen or induction therapy with bortezomib (Velcade)/dexamethasone, followed by high-dose melphalan.

Maintenance therapy has been proven to aid PFS and most likely overall survival, which is critical for patients with high-risk disease. Though a number of patients with myeloma relapse, Wolf maintains that until new drugs become available, initial therapy for myeloma should consist of triplet regimens, transplant, and maintenance therapy.

Jeffrey Wolf, MD

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