I looked up the three small melphalan-prednisone studies on SMM patients mentioned in the abstract. Here are the links: 2009 abstract: http://tinyurl.com/ygnlwr5; 2000 full study: http://tinyurl.com/yjfneba, and 1996 full study: http://tinyurl.com/yhogw2y). A cursory glance shows that there was no difference in survival…indeed, a couple of patients in the first study developed acute leukemia during treatment. Unfortunately, I don’t have time now to read the studies in great detail, but the upshot seems clear: there is absolutely no benefit in administering early treatment to SMM patients. Case closed…as far as I am concerned, anyway.

The study goes on to discuss the administration of thalidomide to SMM patients and concludes that this drug cannot be recommended for the treatment of SMM until a benefit is shown in prospective randomized trials. Caution happens to be my middle name (well, okay…not really! ;-)). Personal note: in 2007, when my hematologist suggested that I take some thalidomide to zap the cancer cells lurking in my bone marrow (=50% at the end of 2005…down to less than 40% at the beginning of 2007 after one year on curcumin), I said no. She tried to insist, but I was adamant. I want my “tiger” to remain dormant for as long as possible…so, no CRAB, no treatment. Period.

As for bisphosphonates, the study states that data from a few SMM trials shows that they might be beneficial for those who have early bone disease, but the potential toxicities of bisphosphonates, such as renal injury and osteonecrosis of the jaw, should be taken into account […]. Wait a sec. I read something recently about bisphosphonates, but can’t recall what, exactly…hmmm…was it good or bad? Oh I know, I read about it on the MMA patient list. I don’t think list members will mind if I post the link, provided by a list friend (thanks!), to this “USA Today” article: http://tinyurl.com/ykguaxm If you are currently taking bisphosphonates, please read this article and ask your doctor about it…

Another thing that we should all keep in mind if some day we face the choice of undergoing conventional treatment: In patients with SMM who then evolve into symptomatic MM the response rate to chemotherapy has ranged from 52% to 64%. I was actually surprised to read that there was such a low response…

Well, okay, so what do we, SMM folks, need to do? The study offers a useful Table outlining the tests that should be done right after we have been diagnosed with smoldering myeloma:

• Medical history and physical examination
• Complete blood count
• Serum calcium and creatinine
• Protein studies
• Total serum protein and serum electrophoresis (serum M-protein quantitation)
• 24-h urine protein electrophoresis (urine M-protein quantitation)
• Serum and urine immunofixation
• Serum free light chain measurement (FLC ratio)
• Beta-2 microglobulin
• Bone marrow aspirate
• Skeletal survey
• MRI of thoracic-lumbar spine and pelvis

After three months, we should have our blood and urine tests repeated…then, if our markers remain stable, we should continue to be checked every 3 months for the first year in order to establish the pattern of evolution (evolving vs nonevolving). If the markers do not remain stable, however, then a full evaluation should be done again, including a bone marrow biopsy. However, SMM folks should not be treated, the authors repeat, until progressive disease with end-organ damage is evident. Especially those who are in the nonevolving category! I couldn’t agree more…

IMPORTANT: A progressive decrease in the Hb level is the most frequent and reliable indicator of progression. Other indicators of progression that mandate treatment are the development of soft-tissue plasmactyotmas or significant skeletal involvement as well as increased serum calcium or a rise in the serum creatinine level.

So please keep an eye on your hemoglobin, in particular…and take action immediately if that number shows any signs of decreasing!