Advances in the management of asymptomatic myeloma

Smoldering multiple myeloma (SMM) is an asymptomatic plasma cell disorder characterized by the presence of one or both features of serum M-protein at least 30 g/l and bone marrow plasma cell infiltration at least 10%. The standard of care is no treatment until symptomatic progression occurs. However, the risk of progression to active multiple myeloma is not uniform, and several markers are useful for identifying SMM patients at high risk of progression to active multiple myeloma. Overall, the presence of these factors is useful to stratify SMM patients according to their risk but the forthcoming challenge is to identify high and ultra-high-risk SMM patients because they can benefit from early treatment.

A randomized trial that focused on high-risk SMM patients allocated to receive early treatment with lenalidomide plus dexamethasone vs. observation did report a significant benefit with respect to time to progression and overall survival.

High-risk SMM patients should be targeted for early treatment, and more such efforts should be made to identify the ultra-high-risk subgroup within the high-risk SMM patient population which may be considered as early multiple myeloma and thereby candidates for receiving therapy before they develop myeloma-related symptomatology.