Thread by @VincentRK

Myeloma FAQs for patients & clinicians. Please add additional questions.

1) Do you still recommend autologous stem cell transplant?

Yes. But for standard risk patients, delaying transplant is an option & gives similar survival (#ASH21 below). Look forward to #ASCO22 plenary.

2) What regimen do use for initial therapy?

VRd for most. Dara plus VRd for young high risk patients as pre transplant induction.

DRd is an alternative to VRd; but you need Dara plus Revlimid for many years. With VRd after 6-8 months it's only Revlimid. onlinelibrary.wiley.com/doi/abs/10.100…

3) What do you use for maintenance therapy?

Lenalidomide alone for standard risk. Lenalidomide plus bortezomib for high risk.

4) How long do you give maintenance therapy?

Until progression if possible.
Reduce dose if needed to keep side effects minimal.

5) What do you use for bone strengthening?

Zoledronic acid every 3 months. I don't use much of denosumab unless there is a particular reason I cannot give zoledronic acid.

6) What dose of Dexamethasone?

No more than 40 mg per week for almost all patients, for all regimens. For people age >70, no more than 20 mg per week for most patients.

7) Is myeloma curable?

Currently myeloma is not curable by the strict sense of the word (Stop all therapy and the cancer never ever comes back in a certain proportion of patients). You can read more on what cure in cancer means here. nature.com/articles/s4140…

8) Are you recommending treatment for smoldering myeloma?

Yes, but only for the 1/3 of SMM patients who have high risk SMM. Recommend 2 years of Len or Rd. Or enroll in clinical trial. More here. @TheLancetHaem @SagarLonialMD @mvmateos thelancet.com/pdfs/journals/…

9) Whats your go to regimen for first relapse?

Not easy to answer. Depends on what patients have had before. If Len sensitive, DRd. If Len refractory, CD38 antibody plus either Kd or Pd. If Len and CD38 antibody refractory, KCd or KPd. onlinelibrary.wiley.com/doi/abs/10.100…

10) How well is immunotherapy working in myeloma?

Very promising. The two approved CAR-Ts are good but still hard to get and very expensive. Bispecifics offer a lot of promise. I haven't used much of belantamab.

11) Does everyone have an MGUS phase before getting myeloma?

Yes. And usually MGUS phase is there for many years. The iSTOPMM randomized trial led by @sykristinsson is testing the role of screening.

12) What imaging do you use annually to monitor bone disease in myeloma?

Whole body low dose CT or PET CT.

13) Whats your treatment for acute light chain cast nephropathy?

Prompt initiation of a regimen like VCd or better still Dara-VCd, along with plasma exchange for a few days till light chain levels are brought down. I take it as a challenge to reverse the renal failure.

14) How established is MRD?

Established as a prognostic marker. But not proven as a biomarker to modify therapy; needs randomized trials to determine such utility. Not proven as surrogate endpoint for trials; needs surrogacy analysis for that. Not proven as a marker of cure.

15) What risk stratification do you use?

See below. Risk stratification helps us with counseling patients on prognosis. Also helps with picking treatments. Patients willingness to take risk is affected by prognosis. Msmart.org

16) How do prognostic factors influence treatment?

Its complex. How you overcome adverse prognosis will be different based on what causes the high risk: high tumor burden vs renal failure vs age versus aggressive biology. Overcoming del17 may need different strategy than t4;14.

17) What are the biggest future challenges?

-Risk adapted therapy
-Testing fixed duration therapy; we cannot only be during trials where everyone gets treatment indefinitely
-Controlling cost
-Cure

18) Do first degree relatives of patients with myeloma have higher risk?

Yes. 2-3 fold. But the absolute risk is low since myeloma is a rare disease. So 4 per 100,000 per year increasing to 8 per 100,000 per year is still a very low absolute risk. Not like inheritable disorders

19) Does race affect risk of myeloma?

Yes. Black people have 2-3 fold higher risk of myeloma. But absolute risk is low since myeloma is a rare disease. So 4/100,000 per year increasing to 8/100,000 per year is still a very low absolute risk. Not like inheritable disorders.

20) What causes myeloma?

Don't know. Likely sequence is a mistake happens when plasma cells divide in response to infection. This establishes MGUS. Then random second cytogenetic hit occurs that causes MGUS to myeloma transition. See below. @BloodCancerJnl