Risk of Myeloma Relapse After Frontline Therapy

James Hoffman, MD: My name is James Hoffman, and I’m assistant professor of clinical medicine at the Sylvester Cancer Center at the University of Miami, Florida, and my clinical and research focus is on plasma cell diseases, such as multiple myeloma and amyloidosis.

Joshua Richter, MD: My name is Dr Joshua Richter. I’m an assistant professor of medicine at the Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai in New York, New York, and the director of myeloma at the Blavatnik Family Chelsea Medical Center at Mount Sinai. And just like Dr Hoffman, my research and clinical focus is on plasma cell dyscrasias, mostly in multiple myeloma.

James Hoffman, MD: The two of us are going to be discussing relapsed/refractory multiple myeloma today, and to get us started, Dr Richter, when it comes to predicting patients’ risk of relapse after initial therapy, what factors or variables do you focus on in terms of making that prediction?

Joshua Richter, MD: One of the things we classically look at is cytogenetic risk factors, looking for high-risk cytogenetic or FISH [fluorescence in situ hybridization] lesions like 17p deletions, 1q additions, and then a number of other presenting factors, such as extramedullary disease or initial presentation with renal dysfunction. We all note that even patients who present with renal dysfunction that gets better quickly, we get a flavor that their myeloma can affect their kidneys and has the potential to be more aggressive down the line. Those are some of the main areas I look for. Anything else?

James Hoffman, MD: I agree completely: aggressiveness of presentation, initial genetics, and the pattern of their initial presentation, whether it was an aggressive presentation or more subtle. Yes, I agree completely with that approach.

Joshua Richter, MD: Along those lines, throwing it back to you, once you are treating these patients initially, how do you monitor or how often do you monitor with blood work or imaging, and what’s your trigger to change therapy?

James Hoffman, MD: These are important questions, and obviously we individualize this for patients based on some of the factors we mentioned, such as what kind of risks they have. But I would say as kind of a standard, we check a full myeloma panel of blood work generally monthly. We don’t really need to check urine laboratory results all that often, so it’s primarily blood work. Certainly, if patients present with new symptoms despite blood work that looks reassuring, we will scan patients in those circumstances, looking for radiologic progression. Then in terms of when we initiate treatment, we all see some patients that can have slow serologic progression but don’t have any clinical progression, and some of those patients can be monitored for quite a bit before initiating therapy. For rapidly rising paraprotein or for any clinical relapse, we would always change therapy. What about you with the same question?

Joshua Richter, MD: I agree completely. It always amazes me how different patients can behave in terms of their relapse. We all follow the IMWG [International Myeloma Working Group] criteria for progressive disease, if the M [monoclonal] spike increases by an absolute of 0.5 g/dL in at least 25%, but exactly like you mentioned, we have people who go over a course of years, from 0.1 to 0.2 to 0.3 g/dL. I have a number of patients, as I’m sure you do, who have technically fit the criteria for progression, but they have no symptoms, the rate has been very slow, and we monitor them. One of the things that’s always in discussion with the IMWG is to include rate of progression or kinetics.

James Hoffman, MD: Perfect, yes, and some of those same rules probably apply to patients with smoldering myeloma who we’re monitoring and trying to figure out when to pull the trigger, and none of us can emphasize enough how individualized treatment approaches need to be for patients. They can be widely different.

Transcript Edited for Clarity