Determining MM Treatment by Risk Category

Additional news from Day 3 of the International Myeloma Workshop in Paris:

I always appreciate listening to Dr  S. V. Rajkumar from the Mayo Clinic. He talked about his practice of putting patients into one of three categories: High risk (about 15%); intermediate risk (10%); and standard risk (75%). This allows him to treat each group differently. (Check out www.msmart.org for specific details.)  

Dr. Rajkumar does not use Melphalan, Thalidomide, High-dose Dex, or Velcade twice/week; and he definitely follows the recommended standard to NOT treat mgus or smoldering MM.

So what does he do? He treats patients in the standard-risk category with Revlimid and low-dose Dex. That practice drew immediate disagreement from another MM expert. Many doctors believe that more treatment up front is better, and that patients should be getting at least a three-to-four drug cocktail, e.g RVd or VMPT. 

"Try your best bullet at the beginning of the disease," says Dr. A. Polumbo. 

For patients who fall into the intermediate-risk category, Rajkumar believes in a Velcade regimen, because Velcade overcomes translocation (4;14) and chromosome 13q deletion, part of Mayo's "intermediate" definition. Velcade is only given once a week and sub-q to minimize side effects.

Rajkumar says he really doesn't know the best treatment for those who fall into the high-risk category, given lack of successful protocols for high-risk patients, but he probably does RVd.

Length of treatment is determined by category as well, says Rajkumar:  18 months for standard-risk patients, then "discuss" maintenance; one year for intermediate-risk patients, then Velcade maintenance once every other week for two years; and for high-risk patients, do whatever is needed to get into a CR, then Velcade until progression.

However, as precise as this may sound, Rajkumar also says: "If anyone says 'xyz is the standard of care,' they are wrong. Rather, they can only offer their opinion."

And in fact, for the rest of the session I listened to descriptions of alphabet soup trials using VMP, VTD, RVD, MPR and more, many followed by maintenance treatments Rev, Vel, or placebo's.