Identifying and treating high-risk patients in 2023

During the Multiple Myeloma Hub Steering Committee Meeting in November 2022, key opinion leaders met to discuss how to identify high-risk patients with multiple myeloma. The recorded discussion was chaired by Professor Sagar Lonial and featured María-Victoria Mateos, Morie Gertz, Paul Richardson, Heinz Ludwig, and Hermann Einsele.

This meeting opens with a discussion on genetics and clinical characteristics and how they inform risk status. Richardson notes that defining patients by genetic risk status alone may be insufficient and the inclusion of clinical parameters should be used to accurately stratify this group. For example, cases harboring the translocation 4;14 or 17p may both be high risk but respond to treatments, such as transplant, differently. The members go on to discuss time to response and MRD status as important clinical factors determining risk; followed by an examination of mutations and circulating plasma cells as predictors of poorer outcomes, with a focus on 1q and translocation 11;14.

There is a need to consider “functional” high-risk patients, including those who progress in the first few years of treatment without high-risk genetics, to establish high-risk pretreatment features, and to consider “post hoc” variables (e.g., time to response) that can also affect outcome and prognosis. There is also a need to consider optimal treatments for patients with special considerations, such as extramedullary disease, and patients who return to a state of monoclonal gammopathy of unknown significance after successful treatment.

The meeting concludes with a discussion on the therapeutic approach for high-risk patients with a consideration for equal access to treatment options.