March 17, 2011 — The latest version of the National Comprehensive Cancer Network (NCCN) multiple myeloma guidelines include a few small changes to reflect recent advances in diagnosis and treatment. They were presented here at the NCCN 16th Annual Conference.
The tweaks include moving the serum free light chain assay from "useful under some circumstances" to a recommended part of the initial diagnostic workup, as well as adding fluorescence in situ hybridization (FISH) for 1q21 amplification.
Both of these tests are now recommended "to more completely evaluate the risk at the time of diagnosis and to help clinicians evaluate whether the disease is standard or high-risk multiple myeloma," panel chief Kenneth C. Anderson, MD, Kraft Family Professor of Medicine at Harvard Medical School and the Dana-Farber Cancer Institute, Boston, Massachusetts, told Medscape Medical News.
"The serum free light chain assay was added to the initial diagnostic workup because it is useful in diagnosis and to follow patients over time. FISH for 1q21 amplification was added to the initial diagnostic workup because it carries an adverse prognosis," he said.
Also, for the first time, the term "symptomatic disease" has been incorporated into the guidelines.
"We changed 'progression to stage 2 or higher disease' to 'progression to symptomatic disease'," Dr. Anderson explained. "This change reflects the more recent categorization of multiple myeloma as either asymptomatic or symptomatic. Progression to symptomatic disease is just to imply that patients need treatment when they develop symptoms or manifestations of myeloma, including hypercalcemia, renal dysfunction, anemia, and bone disease."
In another tweak to the guidelines, "some responses can occur late posttransplant" has been added to the "time point for assessing response" section of the guidelines.
New Treatment Options
New treatment options have also been added. For example, the combination of bortezomib, cyclophosphamide, and dexamethasone was added to primary induction therapy for transplant candidates.
In addition, therapy for primary induction for nontransplant candidates now includes the bortezomib and dexamethasone combination and the melphalan, prednisone, and lenalidomide combination.
New combinations are also recommended for salvage therapy: cyclophosphamide, bortezomib, and dexamethasone; and cyclophosphamide, lenalidomide, and dexamethasone.
"These regimens combine standard agents with novel agents," Dr. Anderson said. "All of these recommendations are category 2A and have been added to the guidelines as options because of the [promising] results of clinical trials."
The guidelines have added novel drugs as initial treatment for amyloidosis. These include bortezomib plus dexamethasone, and the combination of cyclophosphamide, thalidomide, and dexamethasone.
"These updates reflect, very excitingly, the progress that continues to evolve in the treatment of multiple myeloma," Dr. Anderson said. "It's very promising and positive news."
Rajesh Najar, MD, a hematologist/oncologist working in a group practice in Wilkes Barre, Pennsylvania, told Medscape Medical News that these improved treatments will now result in a large number of patients on maintenance therapy.
This will increase the financial burden and will lead to some adverse-effect risks from long-term maintenance, he said. It also raises the issue of how long the duration of maintenance should be.
Dr. Najar said he comes to the NCCN conference because he finds being able to dialogue with oncology thought leaders very useful.
"These are still guidelines and we have to individualize them to suit our patients, but they are very helpful, especially when they quickly incorporate new ideas based on randomized trials," he said. "When I am explaining something to a patient, I know I have good reasons. Plus, there are so many trials going on. As a community oncologist, it is often impossible for me to keep track of every single trial. Here, I get the summaries from the top leaders who have gone through all of these trials. It is a big help."
Dr. Anderson and Dr. Najar have reported no relevant financial interests.
National Comprehensive Cancer Network (NCCN) 16th Annual Conference. Presented March 11, 2011
The tweaks include moving the serum free light chain assay from "useful under some circumstances" to a recommended part of the initial diagnostic workup, as well as adding fluorescence in situ hybridization (FISH) for 1q21 amplification.
Both of these tests are now recommended "to more completely evaluate the risk at the time of diagnosis and to help clinicians evaluate whether the disease is standard or high-risk multiple myeloma," panel chief Kenneth C. Anderson, MD, Kraft Family Professor of Medicine at Harvard Medical School and the Dana-Farber Cancer Institute, Boston, Massachusetts, told Medscape Medical News.
"The serum free light chain assay was added to the initial diagnostic workup because it is useful in diagnosis and to follow patients over time. FISH for 1q21 amplification was added to the initial diagnostic workup because it carries an adverse prognosis," he said.
Also, for the first time, the term "symptomatic disease" has been incorporated into the guidelines.
"We changed 'progression to stage 2 or higher disease' to 'progression to symptomatic disease'," Dr. Anderson explained. "This change reflects the more recent categorization of multiple myeloma as either asymptomatic or symptomatic. Progression to symptomatic disease is just to imply that patients need treatment when they develop symptoms or manifestations of myeloma, including hypercalcemia, renal dysfunction, anemia, and bone disease."
In another tweak to the guidelines, "some responses can occur late posttransplant" has been added to the "time point for assessing response" section of the guidelines.
New Treatment Options
New treatment options have also been added. For example, the combination of bortezomib, cyclophosphamide, and dexamethasone was added to primary induction therapy for transplant candidates.
In addition, therapy for primary induction for nontransplant candidates now includes the bortezomib and dexamethasone combination and the melphalan, prednisone, and lenalidomide combination.
New combinations are also recommended for salvage therapy: cyclophosphamide, bortezomib, and dexamethasone; and cyclophosphamide, lenalidomide, and dexamethasone.
"These regimens combine standard agents with novel agents," Dr. Anderson said. "All of these recommendations are category 2A and have been added to the guidelines as options because of the [promising] results of clinical trials."
The guidelines have added novel drugs as initial treatment for amyloidosis. These include bortezomib plus dexamethasone, and the combination of cyclophosphamide, thalidomide, and dexamethasone.
"These updates reflect, very excitingly, the progress that continues to evolve in the treatment of multiple myeloma," Dr. Anderson said. "It's very promising and positive news."
Rajesh Najar, MD, a hematologist/oncologist working in a group practice in Wilkes Barre, Pennsylvania, told Medscape Medical News that these improved treatments will now result in a large number of patients on maintenance therapy.
This will increase the financial burden and will lead to some adverse-effect risks from long-term maintenance, he said. It also raises the issue of how long the duration of maintenance should be.
Dr. Najar said he comes to the NCCN conference because he finds being able to dialogue with oncology thought leaders very useful.
"These are still guidelines and we have to individualize them to suit our patients, but they are very helpful, especially when they quickly incorporate new ideas based on randomized trials," he said. "When I am explaining something to a patient, I know I have good reasons. Plus, there are so many trials going on. As a community oncologist, it is often impossible for me to keep track of every single trial. Here, I get the summaries from the top leaders who have gone through all of these trials. It is a big help."
Dr. Anderson and Dr. Najar have reported no relevant financial interests.
National Comprehensive Cancer Network (NCCN) 16th Annual Conference. Presented March 11, 2011
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