Should We Treat Smoldering Myeloma YES Lymphoma Myeloma

Additional Disclosures • There is no such thing as Mikhael Oncology James R. Berenson,

Background • Remember Myeloma is a unique cancer – defined by the presence of

What if your friend is walking towards a cliff? • Will you wait until

My Thesis – there are 3 groups within Smoldering Myeloma • Group 1: “Ultra”

Smoldering Multiple Myeloma Ultra-High Risk • >60% BMPC • FLCr >100 • >1 MRI

SMM Paradigm Shift SMM 10% per year x 5 years MGUS ~1% per year

Ultra High Risk SMM = Active Myeloma Not CRAB but now SLi. M CRAB

Bone Marrow Plasma Cell ≥ 60% Rajkumar SV et al. N Engl J Med

FLC Ratio >100 and Risk of progression to myeloma >100 <100 Larsen J, et

Rajkumar SV, Merlini G, San Miguel JF. Nat Rev Clin Oncol 2012

High Risk SMM = Median TTP ~2 years: • Mayo: SMM with M protein

Management of High Risk SMM: What does the data say? Do we believe the

Len/Dex versus Observation in High Risk SMM: TTP Mateos M et al. N Engl

Len/Dex versus Observation in High Risk SMM: OS Mateos M et al. N Engl

Issues with the Spanish Trial 1. Generalizability – Mayo Criteria - BMPC ≥ 10%

2. Tolerability Mateos M et al. N Engl J Med 2013; 369: 438 -447.

3. Consequences Len-dex vs. no treatment: TTP to active disease (n = 119) ITT

Spanish Trial Conclusions • Early intervention in high risk SMM • Prolongs TTP •

Conclusions • Don’t forget new criteria (SLi. M CRAB) for myeloma (Ultra High Risk

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Should We Treat Smoldering Myeloma? YES! Lymphoma Myeloma 2014 Scottsdale, Arizona Rochester, Minnesota Jacksonville, Florida Joseph Mikhael, MD, MEd, FRCPC, FACP Staff Hematologist, Mayo Clinic Arizona

Additional Disclosures • There is no such thing as Mikhael Oncology James R. Berenson, MD • I am not incorporated • I am just the average Joe… President and CEO - James R. Berenson, MD, Inc. Medical & Scientific Director - Institute for Myeloma & Bone Cancer Research (IMBCR) Chief Executive Officer - Oncotherapeutics

Background • Remember Myeloma is a unique cancer – defined by the presence of organ damage – not just pathology • Traditionally we wait until CRAB • But does that really make sense? Do we have to wait until damage is present to intervene? ?

What if your friend is walking towards a cliff? • Will you wait until they are falling to rescue them? • What if they are running? • What if they are enjoying the walk?

My Thesis – there are 3 groups within Smoldering Myeloma • Group 1: “Ultra” High Risk • Plasmacytosis ≥ 60% • Involved/Uninvolved Light Chains ≥ 100 • 1 or more focal lesions on MRI/PET TREAT AS IF TRUE MYELOMA • Groups 2: High Risk (Defn to follow) DEBATE: To Treat or Not to Treat • Group 3: Low Risk DON’T TREAT

Smoldering Multiple Myeloma Ultra-High Risk • >60% BMPC • FLCr >100 • >1 MRI focal lesions High-Risk SMM 25%/year Low-risk SMM 5%/year

SMM Paradigm Shift SMM 10% per year x 5 years MGUS ~1% per year after 10 years

Ultra High Risk SMM = Active Myeloma Not CRAB but now SLi. M CRAB • S (60%) • Li (Light chains I/U >100) • M (MRI 1 or more focal lesion) • C (calcium elevation) • R (renal insufficiency) • A (anemia) • B (bone disease)

Bone Marrow Plasma Cell ≥ 60% Rajkumar SV et al. N Engl J Med 2011; 365: 474 -475

FLC Ratio >100 and Risk of progression to myeloma >100 <100 Larsen J, et al. Leukemia advance online publication 27 November 2012; doi: 10. 1038/leu. 2012. 296

Rajkumar SV, Merlini G, San Miguel JF. Nat Rev Clin Oncol 2012

High Risk SMM = Median TTP ~2 years: • Mayo: SMM with M protein ≥ 3 gm/d. L and ≥ 10% PCs • Spanish: ≥ 10% PCs, Absence (<5%) of normal PCs by immunophenotyping and Immunoparesis of ≥ 1 immunoglobulins • • Abnormal FLC ratio 8 -100 Deletion 17 p, t 4; 14, 1 q amp Evolving pattern Ig. A SMM with M protein ≥ 4 gm/d. L Increased circulating plasma cells Increased plasma cell proliferative rate Rajkumar SV, Merlini G, San Miguel JF. Nat Rev Clin Oncol 2012

Management of High Risk SMM: What does the data say? Do we believe the Spanish Trial? Recall – Randomized, Phase 3 Trial of high risk SMM pts Lenalidomide – dexamethasone vs observation

Len/Dex versus Observation in High Risk SMM: TTP Mateos M et al. N Engl J Med 2013; 369: 438 -447.

Len/Dex versus Observation in High Risk SMM: OS Mateos M et al. N Engl J Med 2013; 369: 438447.

Issues with the Spanish Trial 1. Generalizability – Mayo Criteria - BMPC ≥ 10% and M-protein ≥ 30 g/L or – Spanish Criteria BMPC ≥ 10% or M-protein ≥ 30 g/L and – BM a. PC/n. PC > 95% and – immunoparesis – BUT note that 60% met Mayo Criteria!!

2. Tolerability Mateos M et al. N Engl J Med 2013; 369: 438 -447.

3. Consequences Len-dex vs. no treatment: TTP to active disease (n = 119) ITT analysis Median follow-up: 32 months (range 12– 49) Lenalidomide + dex Median TTP: NR Proportion of patients alive 9 Progressions (15%) 5 pts: early disc followed by PD 4 pts: symptomatic PD No treatment Median TTP: 23 m 37 Progressions (59%) 20 patients: bone disease HR: 6. 0; 95% IC (2. 9– 12. 6); p < 0. 0001 7 patients: renal failure Mateos. ASH 2012 Time from inclusion

Spanish Trial Conclusions • Early intervention in high risk SMM • Prolongs TTP • Improves OS • Does not result in appreciable toxicity • Prevents irreversible damage to kidneys and bones that occur … “on our watch!”

Conclusions • Don’t forget new criteria (SLi. M CRAB) for myeloma (Ultra High Risk SMM = Myeloma) • Low risk can be watched • High risk is complex • Recall 50/50 in 2 years • Consider therapy these patients in an individualized manner • Not limited to len-dex, but all active therapy

Don’t let your patients fall…