Hot off the presses ... the new, March 2014, Mayo Clinic guidelines ("mSMART," or "Mayo Stratification for Myeloma And Risk-adapted Therapy)" for newly diagnosed multiple myeloma:
http://msmart.org/newly%20diagnosed%20myeloma.pdf
Anyone care to take a stab at highlighting some of the key aspects of this revision?
Forums
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Hi Myeloma Beacon Staff, here goes ...
At first read, it appears the standard risk group has been "split", both transplant eligible and ineligible.
For transplant eligible, trisomies retained the previous treatment recommendations of Rd w/ delayed SCT,
But treatment in the t(11;14) and t(6;14) group have been modified.
Induction includes Velcade (CyborD) and straight to SCT, similar to the intermediate group t(4;14) treatment. I am surprised at this. Is there any info detailing the reasoning behind this change (if it is indeed a change from last year's MSMART guidelines) in the standard risk group?
Thanks!
Dana H
At first read, it appears the standard risk group has been "split", both transplant eligible and ineligible.
For transplant eligible, trisomies retained the previous treatment recommendations of Rd w/ delayed SCT,
But treatment in the t(11;14) and t(6;14) group have been modified.
Induction includes Velcade (CyborD) and straight to SCT, similar to the intermediate group t(4;14) treatment. I am surprised at this. Is there any info detailing the reasoning behind this change (if it is indeed a change from last year's MSMART guidelines) in the standard risk group?
Thanks!
Dana H
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DanaH - Who do you know with myeloma?: Myself, SMM as of 1/2012
- When were you/they diagnosed?: 1/2012
- Age at diagnosis: 54
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Here's a link to the discussion last year when the mSMART revision came out then:
https://myelomabeacon.org/forum/mayo-clinic-multiple-myeloma-guidelines-2013-t1810.html
It includes this link to what I think was the version of the mSMART guidelines previous to this year's:
http://www.mayoclinicproceedings.org/article/S0025-6196(13)00077-3/fulltext
https://myelomabeacon.org/forum/mayo-clinic-multiple-myeloma-guidelines-2013-t1810.html
It includes this link to what I think was the version of the mSMART guidelines previous to this year's:
http://www.mayoclinicproceedings.org/article/S0025-6196(13)00077-3/fulltext
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
I am a bit surprised by this as I thought some of the key folks at the Mayo were starting to back off on their recommendation to go to transplant and to instead take more of a salvage therapy approach to SCTs under more circumstances.
For the purpose of this SMART update, which criteria are they using to determine if someone is ineligible for a transplant? (it wasn't obvious to me in reading through this).
I continue to be bothered by the term "Transplant Eligible" since I'm not a auto SCT fan. I realize this is medical term, but to me the use of the word "eligible" implies this is a preferred treatment modality. I would personally much rather see "Drug-Treatment Only Eligible"
For the purpose of this SMART update, which criteria are they using to determine if someone is ineligible for a transplant? (it wasn't obvious to me in reading through this).
I continue to be bothered by the term "Transplant Eligible" since I'm not a auto SCT fan. I realize this is medical term, but to me the use of the word "eligible" implies this is a preferred treatment modality. I would personally much rather see "Drug-Treatment Only Eligible"
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
This new revision of mSMART for newly diagnosed myeloma is the start of a shift to treatments based on underlying cytogenetic abnormalities rather than on risk-stratification. This is a fundamental change. The risk-stratification markers are shown as a continuum above the cytogenetic categories for continuity. As more data emerge, I believe that the treatment paths will diverge. There are many issues that were considered, and I will list a few below.
1. The current risk stratification systems for myeloma, e.g., standard, intermediate, and high risk, include heterogeneous groups of patients. The risk stratification is useful for prognosis, but has limitations when it comes to therapeutic approach. The strategies to overcome risk factors will need to evolve based on what the mechanism of the adverse outcome is.
2. There are numerous cytogenetic abnormalities described in myeloma. Some are considered primary and some secondary. Primary abnormalities start early at the MGUS stage and are likely the initiating event. There are at least 6 major primary abnormalities: t(11;14), t(4;14), t(6;14), t(14;16), t(14;20) and trisomies. While a small % of patients with trisomies may have one of the other ones, these 6 abnormalities are considered non-overlapping, in the sense that the same patient will not have both a t(11;14) and a t(4;14), for example.
In contrast to primary abnormalities, secondary cytogenetic abnormalities -- like del 17p, 1q amp, 1p del, myc translocations, etc. -- occur during the course of myeloma, and can be seen in any of the primary types, and can occur in combination. I view the primary (the big 6) abnormalities almost as unique diseases; the secondary ones can occur in any of the big 6 and affect prognosis.
3. We are only scratching the surface in terms of identifying treatment strategies based on the underlying primary genetic subtypes. We have a lot of data now that specific approaches to therapy can almost fully reverse the adverse risk posed by t(4;14). That is outlined in mSMART. Similarly, we have data from the recent ASH meeting -- based on a study done by my colleague Dr. Shaji Kumar -- that trisomies respond extraordinarily well to Revlimid, while t(11;14) responds well to Revlimid, but not as well as trisomies do. This is also reflected in the new mSMART.
4. High risk due to del 17p is likely a different problem than high risk due to t(14;16) or t(14;20). I think one is driven by biology, the other due to increased risk of renal failure. Stay tuned for future updates that split the treatment paths for these as well.
5. We do not have data for specific abnormalities such as 1q amp in terms of treatment approach. However, most myeloma patients will fit into one of the cytogenetic groups we have listed.
My vision for the future is that we will see risk factors for an estimate of prognosis, but treatment will be individualized based on the specific abnormality that we are dealing with -- not vague groups termed "high risk" or "standard risk".
These are general guidelines, meant for oncologists. Each patient is unique, and a lot of other factors go into determining how to treat an individual patient. Having said that, mSMART provides a more specific recommendation for which of the 20 plus regimens we prefer, and represents the collective wisdom of the 25 plus myeloma docs at the three Mayo Clinic sites in Rochester, Arizona, and Florida.
Moderator's Note: A German translation of the above posting by Dr. Rajkumar can be viewed here in this forum by following this link.
1. The current risk stratification systems for myeloma, e.g., standard, intermediate, and high risk, include heterogeneous groups of patients. The risk stratification is useful for prognosis, but has limitations when it comes to therapeutic approach. The strategies to overcome risk factors will need to evolve based on what the mechanism of the adverse outcome is.
2. There are numerous cytogenetic abnormalities described in myeloma. Some are considered primary and some secondary. Primary abnormalities start early at the MGUS stage and are likely the initiating event. There are at least 6 major primary abnormalities: t(11;14), t(4;14), t(6;14), t(14;16), t(14;20) and trisomies. While a small % of patients with trisomies may have one of the other ones, these 6 abnormalities are considered non-overlapping, in the sense that the same patient will not have both a t(11;14) and a t(4;14), for example.
In contrast to primary abnormalities, secondary cytogenetic abnormalities -- like del 17p, 1q amp, 1p del, myc translocations, etc. -- occur during the course of myeloma, and can be seen in any of the primary types, and can occur in combination. I view the primary (the big 6) abnormalities almost as unique diseases; the secondary ones can occur in any of the big 6 and affect prognosis.
3. We are only scratching the surface in terms of identifying treatment strategies based on the underlying primary genetic subtypes. We have a lot of data now that specific approaches to therapy can almost fully reverse the adverse risk posed by t(4;14). That is outlined in mSMART. Similarly, we have data from the recent ASH meeting -- based on a study done by my colleague Dr. Shaji Kumar -- that trisomies respond extraordinarily well to Revlimid, while t(11;14) responds well to Revlimid, but not as well as trisomies do. This is also reflected in the new mSMART.
4. High risk due to del 17p is likely a different problem than high risk due to t(14;16) or t(14;20). I think one is driven by biology, the other due to increased risk of renal failure. Stay tuned for future updates that split the treatment paths for these as well.
5. We do not have data for specific abnormalities such as 1q amp in terms of treatment approach. However, most myeloma patients will fit into one of the cytogenetic groups we have listed.
My vision for the future is that we will see risk factors for an estimate of prognosis, but treatment will be individualized based on the specific abnormality that we are dealing with -- not vague groups termed "high risk" or "standard risk".
These are general guidelines, meant for oncologists. Each patient is unique, and a lot of other factors go into determining how to treat an individual patient. Having said that, mSMART provides a more specific recommendation for which of the 20 plus regimens we prefer, and represents the collective wisdom of the 25 plus myeloma docs at the three Mayo Clinic sites in Rochester, Arizona, and Florida.
Moderator's Note: A German translation of the above posting by Dr. Rajkumar can be viewed here in this forum by following this link.
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Dr. Rajkumar,
Thank you so much for weighing in on this thread. Your work and comments are to be commended.
Thank you so much for weighing in on this thread. Your work and comments are to be commended.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Thanks, Dr. Rajkumar, for posting on the forum! It's very interesting to read about how the strategies for treating NDMM patients are evolving. I always enjoy reading the articles you write for the Beacon too. As I have mentioned to you before, one of the first books that my husband Dilip picked up at our medical school book store after my diagnosis in 2009 was: 'Treatment of Multiple Myeloma and Related Disorders', by yourself and Dr. R. Kyle.
Since then i have had the opportunity to hear talks by Dr. Kyle, Dr. Gertz and Dr. Joseph Mikhael, and to speak with them also, at patient conferences. They are all authors of the SMART document published in 2013 that Ricardo posted.
Most recently, last month, Dr. Mikhael came to Calgary to speak with our haematological oncologists at the Tom Baker Cancer Centre, and he kindly consented to give a talk afterwards to our patient support group. I had the chance to chat with him after the presentation, which meant a lot to me!
I look forward to reading more of your articles!
Since then i have had the opportunity to hear talks by Dr. Kyle, Dr. Gertz and Dr. Joseph Mikhael, and to speak with them also, at patient conferences. They are all authors of the SMART document published in 2013 that Ricardo posted.
Most recently, last month, Dr. Mikhael came to Calgary to speak with our haematological oncologists at the Tom Baker Cancer Centre, and he kindly consented to give a talk afterwards to our patient support group. I had the chance to chat with him after the presentation, which meant a lot to me!
I look forward to reading more of your articles!
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Nancy Shamanna - Name: Nancy Shamanna
- Who do you know with myeloma?: Self and others too
- When were you/they diagnosed?: July 2009
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Dr Rajkumar,
Thank you so much for providing these explanations which help put this into a much better perspective for me, and easier to understand.
Your commitment gives me such hope.
Best regards,
Dana H
Thank you so much for providing these explanations which help put this into a much better perspective for me, and easier to understand.
Your commitment gives me such hope.
Best regards,
Dana H
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DanaH - Who do you know with myeloma?: Myself, SMM as of 1/2012
- When were you/they diagnosed?: 1/2012
- Age at diagnosis: 54
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Ricardo,
Thanks so much for the links to the 2013 guidelines. Once I reviewed and compared I now realize there was no change in treatment guidelines. It is now more specifically stratified for the standard risk group with the "split" that I first noticed.
All the best to you,
Dana H
Thanks so much for the links to the 2013 guidelines. Once I reviewed and compared I now realize there was no change in treatment guidelines. It is now more specifically stratified for the standard risk group with the "split" that I first noticed.
All the best to you,
Dana H
-
DanaH - Who do you know with myeloma?: Myself, SMM as of 1/2012
- When were you/they diagnosed?: 1/2012
- Age at diagnosis: 54
Re: New Mayo (mSMART) guidelines for newly diagnosed myeloma
Does anyone know what therapy is meant by "Rd"?
Sorry, still new to this and trying to remember the acronyms & abbreviations is more than this chemo brain can handle right now.
Thanks.
Sorry, still new to this and trying to remember the acronyms & abbreviations is more than this chemo brain can handle right now.
Thanks.
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koontzkg - Name: Kathy
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: 2/2013
- Age at diagnosis: 51
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