State of the science in smoldering myeloma: Should we be treating in the clinic?

Currently the standard of care for smoldering multiple myeloma (SMM) is "watch and wait." However, in recent years the treatment for multiple myeloma (MM) has shifted from cytotoxic chemotherapy with poor efficacy to less toxic, more effective treatments. Therefore, the standard for SMM is coming into question, especially for patients at the highest risk of developing MM. There are currently multiple active clinical trials investigating earlier intervention in patients with SMM. This article will review the history of SMM and how the current standard of care came to be. We will define prognostic factors of SMM and how to identify patients at highest risk of developing MM. Next we will review previous clinical trials examining treatment of SMM and finally discuss active clinical trials. While there are clear guidelines outlining management of high-risk SMM patients, they are mostly based on expert opinion and therefore it is an active area of research. Accordingly, patients should be encouraged to participate in clinical trials to better understand the benefit versus risk of early treatment.