A recent report that was published in the Swiss Medical Weekly outlines data gathered by a Swiss panel of experts on plasma cell myeloma. The report offers an update and new insights into a previous review that should add substantial value to clinicians’ decisions on behalf of their patients.
About Plasma Cell Myeloma (PCM)
PCM is generally diagnosed after renal failure, bone lytic lesions (less bone density), or anemia. PCM is a bone marrow-based proliferation (rapid growth) of clonal plasma cells composed of hematopoietic (cellular elements of the blood) neoplasms, which are dysregulated proliferation of cells. This is caused by genetic mutations.
About Smoldering Myeloma
Smoldering myeloma is identified according to levels of serum M-protein, or when 10 percent (or higher number) plasma cells are found in the bone marrow, without any damage to organs or tissue.
Patients with smoldering myeloma may have minimal disease progression for a long period of time. However, there is a ten percent risk that it will evolve into symptomatic myeloma in the first five years, three percent during the next five years. The risk is reduced to one percent in subsequent ten years.
A small study was conducted to investigate the effect of early treatment for smoldering myeloma. The drugs lenalidomide and dexamethasone were compared in one group against observing patients in the other arm. The researchers recorded progression free survival and overall survival when administering early treatment. However, it was determined that the trial (125 treated patients) was too small to recommend early treatment and that further trials were needed.
Monoclonal Gammopathy of Undetermined Significance (MGUS)
MGUS is the result of the overproduction of abnormal M proteins in the white blood (plasma) cells of the bone marrow. Usually people will not experience symptoms other than a possible rash, or nerve disorders such as tingling or slight numbness.
If a patient presents with ten percent or fewer bone marrow clonal cells and doesn’t have damage to organs or tissue, the diagnosis is usually MGUS. However, if there is an accumulation of M Protein, it can crowd out healthy cells in the bone marrow and cause damage to tissues.
Generally, MGUS will not create significant problems– but, it’s always possible that at some point in time there will be a progression to other diseases, including blood cancer. To monitor this risk, periodic testing is recommended. The cause of MGUS is not known but environment and genetic changes may be responsible.
Today, tomography of the bone is standard of care as it can detect small bone defects. It is a precise tool in analyzing asymptomatic patients with suspected myeloma.
A Plethora of New Drugs
A previous clinical trial that confirmed the importance of stem cell transplant, treated patients with lenalidomide and dexamethasone for induction (initial treatment). The combination of these two drugs is now considered less effective than a triple combination which should still be used as standard of care for elderly patients.
Three drugs used as first line treatment in a recent French trial were bortezomib, lenalidomide and dexamethasone. This combination is preferable as therapy in patients who are eligible for transplants. It is also a consideration for patients who are fit but ineligible for transplants.
Lenalidomide is a consideration for most patients, over a two-year period, who have undergone stem cell transplants.
Several combinations are under consideration for transplant ineligible patients who are able to tolerate multiple drugs:
- daratumumab with bortezomib
- melaphalan and prednisone
- lenalidomide and dexamethasone
- daratumumab in combination with dexamethasone, pluslenalidomide or bortezomib
- carfilzomib, ixazomib, or the monoclonal anti-SLAMF7 antibody elotuzumab with lenalidomide and dexamethasone
The preference of each patient should be a consideration in treatment options as well as comorbidities (other diseases or medical problems), toxicity, and previous treatments.