Should you start treatment early in smouldering multiple myeloma?
Dr Albert Oriol - Josep Carreras Leukaemia Research Institute, Barcelona, Spain
My presentation is going on smouldering multiple myeloma, this is early multiple myeloma – multiple myeloma that has not given symptoms yet. Up to now, differently than other cancers, we haven’t been treating those myelomas until they gave symptoms but there’s enough evidence right now to make early treatment and avoid the appearance of all these complications. What’s not so clear is what’s the best treatment for these kinds of patients and that will be part of my discussion - several trials that are trying to focus on smouldering multiple myeloma options.
Could you tell us more about any of the ongoing trials that you referred to?
There are several trials but basically there are two kinds of trials which are important, those that are focussing on a very mild treatment with very few side effects and that you can do for a long time that are trying to delay the appearance of symptoms but not curing and then there’s the other option which is doing highly intensive treatment in order to cure the disease at its early moments before it gives symptoms. Of course these two options are completely different in scope and intention and we don’t really have the data to say which strategy is better.
Before deciding on a strategy, what should clinicians take into account?
Of course tolerance of the patient, age, comorbidities, performance status; of course a very intensive treatment is only an option for very fit patients. But most of these patients are fit because they haven’t given symptoms get. So, unless they are very old or they have several other diseases or several other conditions, that would be a good option.
Is there opportunity for these treatments to be personalised and move towards precision medicine?
We always try to do things in a personalised manner but sometimes it’s not that obvious. In fact, treatment for myeloma is not personalised in general because we have the best treatments that are the best for every patient, we don’t have subgroups of patients that go better with an alternative treatment. So the options we have is just, as I told you, either you give a very mild treatment for the patient that is not fit enough to have a more intensive one or you try to do your best with the best treatment available.
Are there any prognostic factors or biomarkers currently available?
Yes, there are but regarding treatment and personalisation of treatment, prognostic factors only tell you how difficult it will be to treat that patient. It’s not going to direct you to a specific treatment. So the best available treatment is the best treatment for any patient regardless of prognostic factors.
What do you foresee in the future of this field?
Of course we’ve been having two combination treatments with high intensity at the beginning and with maintenance treatment to continue further on, probably for years, in order to achieve probably a curation of a proportion of patients. Up to now myeloma is not curable but we have evidence that if we treat myeloma enough there’s a proportion of patients that will never relapse or will relapse in many, many years’ time. So, of course, we are trying to improve treatment a little bit more in order to have a curable option.
It’s a field that’s moving very fast so we were somehow reluctant to talk about curation in myeloma because we know that relapses can happen ten years after or fifteen years after a good response. But, of course, we have to start to think that that’s an option and if that’s an option we have to try to improve. We have lots of weapons we can use, we only have to look for the best combination and the duration and how we have to use them in order to cure.