Transplant Ineligible Multiple Myeloma: Updates to the MAIA Study - Episode 1

Risk Assessment and Goals of Therapy in Multiple Myeloma

Peter Voorhees, MD, provides a broad overview on risk assessment and the goals of therapy in multiple myeloma management.


Peter Voorhees, MD: How do we determine risk in newly diagnosed patients with myeloma? There are a number of factors that we look at. One is the cytogenetic risk factors. Does the patient have a myeloma that harbors del(17p) or 1 of the high-risk IGH translocation such as 14;16, 14;20, or 4;14? There’s an increase in the body of literature supporting increased risk with regard to gain of 1q21.1. In particular, 4 or more copies are harbored by the multiple myeloma. We also look at the International Staging System [ISS]. Patients with ISS stage III disease certainly don’t fare as well as their stage I and II counterparts. Then there’s the revised ISS, which incorporates cytogenetic risk and high LDH [lactate dehydrogenase], which we know is a marker of more aggressive proliferative disease along with the ISS. There’s a number of other factors that we look at, including the presence of circulating plasma cells in peripheral blood; 5% or more typically connotes a more aggressive version of multiple myeloma. Advanced imaging techniques, such as PET [positron emission tomography]/CT, can help us determine whether there’s the presence of extramedullary multiple myeloma at the time of diagnosis, which is also an indicator of high-risk disease.

The goal of treatment for a patient with newly diagnosed multiple myeloma is to drive the disease into as deep of a remission as possible and, by doing so, ameliorate the morbidities they’re experiencing related to their multiple myeloma at the time of initial diagnosis and to prevent additional morbidity arising as a result of their multiple myeloma over the long term. Deep remission and sustained remission achieve both of those goals, but we want to do it in a way that’s not overly toxic with regard to adverse effects.

How do we determine if a patient is eligible for autologous stem cell transplantation? Increasingly we’re using age less frequently as that determinant. There are a good number of patients 70 years of age and older, and they’re perfectly capable of getting through high-dose melphalan chemotherapy, just as well as their 50- and 60-year-old counterparts. We look at fitness frailty more than we do chronologic age. Does the patient have comorbidities that would impact the safety of going through high-dose chemotherapy? There are a number of frailty scores, including 1 that was adapted by the International Myeloma Working Group that could help predict potentially more severe adverse effects related to treatment for patients with myeloma. Those metrics can be very helpful in making a decision about whether to proceed with transplant.

Transcript edited for clarity.