Introduction and Defining Disease Progression in Multiple Myeloma

Dr. Ajay Nooka, director of the Myeloma program at Winship Cancer Institute of Emory University, simplifies the International Myeloma Working Group criteria for disease progression, explaining that community oncologists need not rely on complex semantics. He distinguishes between refractory disease (continued M-protein elevation while on treatment) and relapsed disease (disease recurrence after treatment discontinuation during remission).

The discussion emphasizes how frontline therapies have become increasingly effective, with patients maintaining longer remissions through extended maintenance therapy. Meta-analyses demonstrate that maintenance therapies significantly improve overall survival. The most common clinical scenario involves patients progressing on lenalidomide maintenance after receiving effective induction therapy, with or without transplant.

Critically, Dr. Nooka differentiates between losing remission and needing treatment initiation. He identifies three scenarios requiring prompt treatment: patients with high-risk cytogenetic abnormalities (either at diagnosis or acquired at relapse), functionally high-risk patients (those progressing within 2-3 years despite effective therapy), and patients presenting with symptomatic relapse causing organ damage. In contrast, standard-risk patients with slowly progressive biochemical relapse may be monitored without immediate intervention, as this represents the optimal time when minimal disease burden can be controlled with minimal treatment burden.