Is It Time for a More Holistic Approach to the Treatment of Multiple Myeloma?

Round 1

Reviewer 1 Report

Multiple Myeloma (MM) is more commonly seen in elderly patients and remains an incurable disease, while novel drugs promote patients' survival in recent decades. Thus how to help patients live with the disease and improve patients' quality of life becomes an important issue. The authors of this article provide their valuable opinion that MM should be treated with a more holistic approach instead of the traditional specialist-patient mode, which means ANP, SNP, pharmacist and cancer specialist all play roles, in both synchronous and independent ways. The article is well written and organized.

Author Response

Thank you for your kind comments.

Reviewer 2 Report

While this manuscript provides a holistic picture for myeloma treatment, the aspect of molecular diagnosis should ideally be included in the section of The Myeloma Specialist.

There are many treatment options, including new treatment options has improved the survival of the patients. However, not all patients respond to a given treatment. Fewer than 50% of the myeloma patients benefit from the treatment with bortezomib, for the patients who do not respond to bortezomib, they are over-treated or wrongly treated.

In this aspect, I would suggest to include the content of molecular diagnosis, particularly the classification based on MCL1-M. Only myelomas with high MCL1-M expression will benefit from bortezomib treatment, whereas the other myelomas with low MCL1-M expression will not benefit from bortezomib treatment (Genes Chromosomes Cancer 57:420-429.). Application of MCL1-M classification in the future should help > 50% of the myeloma patients to avoid the side effects of bortezomib treatment, and also greatly reduce the treatment cost.     

Author Response

Thank you for this suggestion. We agree that risk stratification of myeloma patients is vitally important. We have included the following in the section 'The Myeloma specialist’:

“ At diagnosis, the MM clinician should score patients using the Revised International Staging Score (R-ISS) which uses β2 microglobulin, albumin, lactate dehydrogenase and the presence of cytogenetic abnormalities (17p13 deletion, t(4;14) and t(14;16)) to define three prognostic groups. Next generation sequencing techniques are revealing the complex genomic landscape of MM with an increasing number of genetic mutations now identified, as being associated with a poor prognosis—for example, CCND1, ATM and TP53.  

The challenge is how to use this cytogenetic and genetic information to tailor therapy. The poor risk associated with t(4;14) is partly overcome by treatment with bortezomib-based therapy and t(11:14) (3)  The degree of MCL1-M expression may also help define who may benefit from bortezomib treatment (4).  Tailored therapy will hopefully improve clinical outcomes and reduce the costs and potential toxicities associated with ineffective treatment.”