Under the Bright Lights of ASH

Under the Bright Lights of ASH

December 10, Friday 

Friday was a light day, program-wise. Even so, I was immersed quickly into the bright lights of ASH. I learned a lot by attending an excellent symposium, Adapting Clinical Practice to a Rapidly Changing Therapeutic Landscape in Multiple Myeloma, moderated by Dr. Brian Durie (IMF & Cedars-Sinai), and including myeloma specialists Dr. Jesus San-Miguel (University of Navarra, Spain), Dr. Philippe Moreau (University Hospital of Nantes, France), Dr. S. Vincent Rajkumar (Mayo Clinic, Rochester), and Dr. Thomas Martin (UCSF). This program detailed various case studies along the myeloma continuum.  

The first dealt with smoldering multiple myeloma (SMM), which I’ll be focusing on: Evidence for Treating High Risk Smoldering Multiple Myeloma. The definition of high-risk smoldering myeloma (HRSMM) was reviewed, and the details of a case study were outlined. The experts weighed in on whether to treat or not, and if so, how? Interestingly, there wasn’t a consensus about treating, which highlights a challenge those with smoldering myeloma may face. Those who are high-risk can enter treatment through a clinical trial, and possibly off-trial, too, and thus clear-cut decision points don’t exist. The experts highlighted that the rationale for early treatment is either to delay progression or to cure the disease.  

Discussion ensued, and it was really interesting to follow along with these specialists as they considered key data points and rationales for one approach over the other. In the end, I came up with these takeaways:  

  1. Patients with HRSMM should be followed very closely, approximately every two months, as progression consists of an evolving pattern of change.  
  1. Use SLiM CRAB for treatment guidance, as the goal is to treat before active CRAB symptoms are evident.  
  1. Progression is hard to capture at the moment, as it happens between visits (see #1 above).  
  1. Dr. San-Miguel predicted that the 2 in the 20/2/20 risk progression model may be replaced with .2 in the future.  
  1. Although not discussed, the question about who decides treatment in HRSMM arose. Specifically, how much input should patients have, or should the physician decide exclusively? I wish they discussed this.  
  1. Dr. Thomas emphasized the importance of gathering and observing trends in key myeloma markers; he wants to see “the movie,” versus individual snapshots. 

December 11, Saturday 

As the first official day of ASH 2021 began, I had the opportunity to sit in at the International Myeloma Working Group breakfast, where investigators shared some research highlights. This was fascinating as the best in the myeloma world asked questions and discussed recent findings…wow! 

I also attended a variety of other presentations. A couple of key points that I’d like to share are as follows:   

  1. Results from the iStopMM (Iceland Screens, Treats, or Prevents Multiple Myeloma) project are coming out. If you don’t know about this project, it is really quite amazing! Iceland has been able to screen about half of its adult population (40+ years old, over 75,000 people) for MGUS and SMM, via M-protein and abnormal FLC ratio. The prevalence of SMM in the total population is estimated to be about .5%, with prevalence increasing with age. Of those with SMM, about a third were considered to have intermediate or high risk SMM. Risk was assessed with both the Mayo 20/2/20 model and the Spanish model, which resulted in 55% agreement. They concluded that a need for improved risk stratification exists. A future direction with this data is to continue to follow these individuals, as well as to explore the possibility of familial connections, correlations with autoimmune issues, and psychological outcomes related to knowledge of having SMM.  
  1. Early research is looking at the possibility of following smoldering myeloma via liquid biopsies (i.e., from plasma) versus bone marrow biopsies (BMB). BMBs, which are currently the “gold standard,” are invasive and often painful, and thus, are done at diagnosis and then later when other labs show that progression may be occurring. They also tend to be “patchy,” meaning that results are somewhat sample-dependent. Two papers (Garces and Dutta) highlighted the possibility of liquid biopsies, comparing results to BMB. The early work looks promising, so we’ll have to stay tuned in the coming few years on this front.  

I’m not finished with Day 1 yet, as I’ll be attending one more oral session and then, at least six poster presentations. My general impressions are that ASH certainly brings the best and brightest together as they shine light in the myeloma space. I’m taking in as much as I can, and I hope that what I share is of interest and value to you!  

Jessie Daw, on Twitter: @Daw6Jessie 

To Treat or Not To Treat?

To Treat or Not To Treat?

The IMF CCO CME Friday Satellite Symposia is a physician educational activity that is available for those who register, either for the online virtual or in-person option.  

The diagnosis of active multiple myeloma (MM) and when to initiate therapy for patients with MM continues to evolve as we learn more about the biology of this disease and how we can use various biomarkers to determine the risk of progression to active disease. 

Currently, some consider beginning therapy for patients with smoldering multiple myeloma (SMM) once they have >50% risk of progression to active disease based on the 20/2/20 model. Some healthcare professionals feel uncomfortable and do not wish to start treatment for high-risk smoldering multiple myeloma (HRSMM), and ongoing monitoring happens. Today, we are hearing that we need more than the 20/2/20 model to determine treatment for HRSMM. 

I’m sure some of the other #IMFASH21 Team Leaders will blog on other cases presented at the Symposium, but I’ll focus here on the HRSMM. Below is the excellent agenda for the IMF Symposium where 6 cases were presented, voted on, discussion ensued, voted on again.   

Dr. Jesus San-Miguel (Clínica Universidad de Navarra – Pamplona, Spain) presented virtually on “Case Study 1: Evidence for Treating HRSMM.”

To Treat or Not to Treat for HRSMM: 

When I was diagnosed 21 years ago, there was not even a classification of HRSMM vs SMM. I remember at previous ASH when these discussions and research first started and the interest that developed. Today we have from the International Myeloma Working Group (IMWG) progression risk by group, see below: 

“Having these tools helps a SMM determine to treat or not to treat – but you need more than 2/20/20!” – Dr. Jesus San-Miguel.

Today, my rock n’ roll reference song is “Treat Me Right” by Pat Benatar (1980).

Enjoy! 

Michael Tuohy, on Twitter: @IMFmikeMYELOMA