Multiple Myeloma

An article in the Nov. 25 issue noted that treatment is urged for high-risk smoldering multiple myeloma. Moreover, this year other articles, including one by Vij selecting the best myeloma research in 2011 (2/10/12 issue), extensively addressed innovative drugs for relapsed refractory multiple myeloma. However, these compounds have not been associated with cure. Cure has only been reported after upfront aggressive treatment including autologous transplantation, and in this regard the work of the Arkansas Group and a Spanish study was referenced. Cure has also been reported after radiotherapy and allogeneic hematopoietic cell transplantation.

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Last year at a meeting there appeared uncertainty about cure and treatment of multiple myeloma. Young transplant-eligible patients, appear to be treated as older patients and recommendations suggest triple or even double combinations as upfront treatment. It is predictable that these patients relapse.

The combinations in multiple myeloma are by far not as aggressive as in leukemia or lymphoma, and the question arises as to why. It seems to me that if patients with multiple myeloma were given the typical drug combination for acute myeloid leukemia (cytarabine and daunorubicin or idarubicin) or for diffuse large B-cell lymphoma they might, in particular when CD20+ is expressed, achieve higher complete remission rates.

It remains unclear why young multiple myeloma patients remain tickled with double- or triple-drug combinations, typically given in multiple myeloma.

This uncertainty motivated us to research multiple myeloma, and with our older program as background (proposing dose-dense induction, two semi-high-dose conditioning autologous transplants, and a reduced-intensity conditioning allogeneic transplant1), a new program was designed that also addresses earlier stages (smoldering) multiple myeloma.

Work done by Mateos et al2 shows that smoldering multiple myeloma should be treated aggressively as well; the reported study addresses that a double combination does extend progression-free survival and induces a trend towards improvement of overall survival. This result does not need to be repeated; the conclusion from this study is to be aggressive if cure is the goal; and in younger patients, to not wait until they develop high-risk smoldering multiple myeloma but to be aggressive even at earlier stage. For cure the disease needs to be eradicated; maintenance is not an option.

Transplant Creations' new program, with a brief but incomplete preview at http://www.transplantcreations.org), aims to work with centers and national organizations on cure.

We invite investigators in Europe and North America interested in this program to contact us and enjoy the webinars we are setting up and to get information, after which we will discuss with centers how we can support implementation of work on cure.

MARLIES VAN HOEF, MD, PHD, MBA

Transplant Creations

Amsterdam, The Netherlands

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