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Could Earlier Treatment Delay Onset of Full-Blown Myeloma? Questions Raised at ASH 2013

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New Orleans, LA December 7, 2013--Today was the official start of the annual meeting of the American Society of Hematology (ASH) with the Exhibit Hall open, posters displayed and education talks presented, which is what I'll start with. This session featured three renowned myeloma experts, each speaking for about 30 minutes: Dr. Ola Landgren (National Cancer Institute), Dr. Maria-Victoria Mateos (Spain) and Dr. Phillip McCarthy (Roswell Park Cancer Institute, Buffalo, NY). All three doctors summarized what is known at this instant in time, pending future announcements at ASH.

Dr. Landgren discussed MGUS and smoldering myeloma (SMM) in terms of biological insights and early treatment (contrary to the current watch and wait recommendation). I found it interesting that he mentioned one could think of myeloma as a metastatic disease that evolves from a Solitary Plasmacytoma (passing through the MGUS and SMM phases). While MGUS only has a .5-1%/yr progression to full-blown myeloma, SMM is much higher at 10%/yr during the first 5 years. All of this says that many of us had precursors to myeloma before we were diagnosed.  

So one might ask if earlier treatment would have delayed the onset of full-blown myeloma. This is a relatively new area of investigation with several clinical trials examining possible answers.  These trials are incorporating difference risk stratifications for SMM patients so that ultimately High or Ultra-High Risk SMM patients may benefit with early treatment whereas MGUS and standard-risk SMM patients may still fall into the watch and wait category. We'll see what happens as these trials progress.

Dr. Mateos focused on summarizing treatments available for non-transplant ("elderly") patients. She indicated the importance of evaluating such a patient as being Fit, Unfit, or Frail.  All the well-known treatments are available to "Fit" patients, while "Unfit" patients may benefit by lower dosages and "Frail" patients should avoid Melphalan.

I found several posters of interest.  (You can actually look up the abstract for these posters by going to www.hematology.org and looking up the poster number, which I'll identify within square brackets [ ]. The actually poster may contain updated information.)

• Poster [1888] suggested that if a solitary plasmacytoma has abnormal PET-CT scans and serum Free-Light-Chain values, perhaps myeloma treatment should start after appropriate surgery/radiation.

• Poster [1933] demonstrated that Carfilzomib plus Melphalan and Prednisone for newly diagnosed elderly patients is a promising therapy. In a Phase I/II trial, it showed an Overall Response Rate (ORR) of 91%, including 10% Complete Response (CR) and 45% Very Good Partial Response (VGPR).

• Poster [1940] looked at Pomalidomide plus Velcade plus Dex in patients with relapsed/refractory myeloma (RRMM). This PVD regimen showed ORR of 90% for patients refractory to Revlimid.

• Poster [1974] showed Bendamustine, Velcade and Dex (BVD) for RRMM patients an effective treatment with ORR-77% (CR 20%, VGPR 20%)

• Poster [1979] explained that treatment with Pomalidomide directly after being treatment with either Revlimid or Thalidomide actually has lower response rate and shorter treatment duration.

Tonight I attended International Myeloma Foundation (IMF) Grant Awards reception, where four myeloma patients shared their personal stories and the IMF awarded a number of $80K and $50K grants to researchers primed to make new discoveries benefitting patients in the future.

Definitely a nice way to end the day. 

-- Jack Aiello

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