Determining When Treatment for Patients With High-Risk Smoldering MM is Appropriate
Faith Davies, MD, NYU Langone Health, New York, New York, participated in a debate at the 2025 Great Debates in Hematologic Malignancies meeting in New York, New York, in which she argued primarily in favor of not treating patients with smoldering multiple myeloma (MM) because it is not a well-defined disease, and progression to active MM can be difficult to estimate.
Dr Davies concluded, “I think it's very much dependent on the patient—how the patient feels about these things, and making sure that the patient knows the pros and cons about both approaches so that they can then be involved in their decision and make the best decision for them.”
Transcript:
My name's Faith Davies, and I'm a professor of medicine at NYU Langone Health in New York. I'm here at the Great Debates in Heme-malignancies in New York City, and I've just come off the stage having debated with Dr. Voorhees about whether we should or shouldn't be treating patients with smoldering myeloma.
I have to say it was quite fun because it truly is one of those difficult questions in myeloma at the moment. There are 3 randomized studies using lenalidomide, lenalidomide and dexamethasone or daratumumab, all of which show that patients have a longer time before they go on to develop myeloma and therefore suggesting that we should be treating all high-risk patients with smoldering myeloma with therapy.
One of the problems is that over the years, the criteria for smoldering myeloma has changed a little bit, and obviously treating a patient with smoldering myeloma, it does unfortunately have some side effects. There's this whole discussion as to whether this is the best thing to do or not.
I was actually on the not side, and my arguments were ranging from the fact that smoldering myeloma isn't a defined entity. There are some smoldering myeloma patients who may not progress for many years, and then other smoldering myeloma patients who may progress in a few months’ time. We also, as I say, have the criteria which are good, but need to be improved. Indeed, the International Myeloma Working Group and the International Myeloma Society are going to meet later this year to try and tweak them a little bit and make them a little bit stronger.
I think for me, a couple of the things I found very interesting is that when you look at those studies in a little bit more detail, not all patients respond to those treatments. If we're going to cure something, we need patients to respond to the treatment. That's one of the kinds of minor sides, if that's the right expression for starting treatment for these smoldering patients.
One of the other things is about when we do treat patients, are we improving their progression-free survival? Those studies would definitely say yes, but also, are we stopping some of the end organ damage? That one's a little bit more controversial. It may be that we're stopping some of the anemia, but I think it still seems to be that patients are maybe not getting those bad bone disease issues. They may have a few changes on MRI if you start treatment, but don't necessarily have those lytic lesions and so on.
The final discussion is that with all of the new data that's out there with the 4-drug regimens, we're actually doing a very good job of treating myeloma now. So should we be starting treatment earlier or later? Dr. Voorhees and myself, we had a good back and forth.
I'm not entirely sure either of us won for the very simple reason that I think it's very much dependent on the patient—how the patient feels about these things, and making sure that the patient knows the pros and cons about both approaches so that they can then be involved in their decision and make the best decision for them.
Source:
Davies F. Debate- Should All Patients with High-Risk Smoldering Myeloma Be Treated? Yes vs No. Presented at the Great Debates in Hematologic Malignancies meeting. June 28-29, New York, New York.
