When should treatment for multiple myeloma (MM) be initiated?

Updated: Sep 30, 2019
  • Author: Dhaval Shah, MD; Chief Editor: Emmanuel C Besa, MD  more...
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Answer

An important study by Dimopoulos and associates evaluated the risk of disease progression in asymptomatic subjects with MM. [30] This study evaluated 638 consecutive untreated subjects with MM. Of these subjects, 95 were asymptomatic and were not treated until their M protein value rose to greater than 5 g/dL. These subjects developed increased bone disease or symptoms of bone disease.

The individuals in this group were designated as either low risk (ie, no bone disease, M protein level < 3 g/dL, or Bence Jones protein level < 5 g/24 h) or high risk (ie, lytic bone disease and serum M protein level >3 g/dL or Bence Jones protein level >5 g/24 h). Intermediate-risk subjects did not have bone disease or an M protein level greater than 3 g/dL or a Bence Jones protein level greater than 5 g/24 h. The patients were evaluated every 2 months.

The median time for disease progression was 10 months in the high-risk group, 25 months in the intermediate-risk group, and 61 months in the low-risk group. [30] At the time of progression, subjects were treated with standard chemotherapy. Their response rates did not significantly differ from those of unselected populations. Median survival time from the institution of chemotherapy did not differ among the groups. Thus, asymptomatic subjects did not benefit from early treatment, and delayed treatment did not affect treatment efficacy (ie, survival).

A systematic review by He et al demonstrated a reduction in vertebral compressions and time to progression with early systemic treatment for asymptomatic patients, but this study also revealed an increase in acute leukemia in the early treatment group. [31] The failure to demonstrate improved survival may be due to the small number of patients studied.


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