<p>Patients with high-risk multiple myeloma have poorer prognoses and less durable responses to treatment compared with patients who have standard-risk disease. Therefore, doctor-patient discussions in this setting should foster clear understanding for the patient, with shared decision making focused on selecting appropriate treatment strategies and, ideally, enrollment in clinical trials.</p>

Although we have made significant strides in the treatment of multiple myeloma, patients with high-risk disease, unfortunately, still have much shorter remissions and survival than those who do not have high-risk features. The factors involved in high-risk disease include a patient’s genetics, disease stage, and clinical response to frontline therapies, as well as extramedullary disease. There are also patients who might not have any high-risk disease features at diagnosis but still do not achieve the level or duration of remission that we might anticipate.

 

Genetic features indicating high-risk disease include del(17p) and TP53 mutations. In addition, we pay particular attention to patients who have amplification of chromosome 1q. The more copies of chromosome 1q someone has, the higher their associated risk. When discussing genetic features of disease, I always assure patients that this is not something that they had any control over or did anything to create. Patients who have extramedullary findings have disease that tends to behave more aggressively. Even if these patients experience a response, those responses are often not durable.

 

We do our best to explain these high-risk disease–related factors to our patients, all the while maintaining hope and encouragement as we work to continue to improve the therapeutic options for high-risk multiple myeloma. It is important for us to share our current knowledge about multiple myeloma with our patients and to help them understand the biology of their disease. I try to enroll my patients with high-risk multiple myeloma in clinical trials at each juncture when treatment is needed, from newly diagnosed through relapsed and refractory disease. Ideally, we would ensure that those who have high-risk disease enroll in clinical trials as frequently as possible.

 

Hopefully, we can continue to make advances across the spectrum of treatment. However, it is also important to temper expectations to a degree. Unfortunately, patients with high-risk disease do not always see the same benefits from new therapies as patients whose disease does not have high-risk features.