mSMART: A clear and simple guide for treating patients with multiple myeloma

Jan. 23, 2021

S. Vincent Rajkumar, M.D., hematologist-oncologist at Mayo Clinic's campus in Rochester, Minnesota, talks about mSMART multiple myeloma treatment guidelines, how they are useful for physicians worldwide and the latest developments in these recommendations.

What does mSMART stand for?

mSMART stands for Stratification for Myeloma and Risk-Adapted Therapy, which are continuously updated Mayo Clinic multiple myeloma treatment approach guidelines. We purposely chose a non-English word — an acronym — for the guidelines, so it would be easily internet searchable.

Why did you and your team create mSMART, and for whom were the guidelines developed?

In 2007 and prior, multiple myeloma treatment decisions were a free-for-all. There were no particular guidelines. Controversy arose with drugs such as zoledronic acid (Zometa), which was more expensive and increased risk of jaw osteoporosis, and we thought it made sense to provide some treatment parameters.

We decided we should think in these terms: "If we personally — or our loved one — had multiple myeloma, what should we be doing for that patient, and what should our general recommendations be?"

mSMART was designed for physicians external to Mayo. The guidelines were written specifically to be clear, simple and easy to use. In fact, Rafael Fonseca, M.D., Mayo Clinic Cancer Center interim director, hematologist and multiple myeloma specialist, has called the advent of mSMART a staple of Mayo Clinic's engagement with those who treat multiple myeloma and a reference in the myeloma community.

Our Mayo Clinic myeloma investigator team published its first paper with myeloma treatment guidelines in a 2007 Mayo Clinic Proceedings issue. We've published updates in 2009, 2013, 2015 and 2017. We also maintain a website with the latest guidelines,

How have these guidelines been received?

They've been widely received very well. mSMART guidelines are ranked pretty high in Google. If you do an internet search on "myeloma guidelines," they come up. The site is accessed worldwide.

What are some significant milestones of mSMART since its inception?

In 2007, we introduced myeloma risk stratification, or risk-adapted therapy. We have continuously updated our risk stratification criteria. Our research group recommends modification in treatment based on whether the patient's disease is deemed low risk, with a current median survival of approximately eight to 10 years, or high risk, with a current median survival of approximately three to four years. For example, for patients with high-risk myeloma, we recommend more-aggressive induction therapy, early transplant and bortezomib-based maintenance. We believe by following our treatment recommendations we can narrow the outcomes gap between low- and high-risk patients.

In 2019, our group published the first paper ever to refer to multiple myeloma in plural — as myelomas — and indicating the time to consider it one disease is over; there really are six myeloma types.

How do I know I can trust these guidelines for treating my patients with myeloma?

Our goal is not to promote Mayo Clinic, though the Mayo Clinic multiple myeloma research and treatment history is such that others do look to us. The real reason for these guidelines is this is what we believe is in the patient's best interest. Medications we don't recommend in mSMART may be unproven, too expensive or too toxic, for example.

mSMART is constantly updated and evidence-based. It's current because it's a living document. When we change our document, it reflects a change in our practice. We have a large group behind mSMART — a lot of brains on this project.

Have these guidelines had any interest from patients?

We've found many patients with myeloma go to the mSMART website and then take the guidelines to their physicians.

How do these guidelines help physicians?

So many patients want to come to Mayo Clinic, yet our capacity is limited. By and large, more hematologists are comfortable treating multiple myeloma today, and we want to help them do right by the patient. Recently, many new drugs have been approved.

While this is exciting for the field, it can also pose questions for physicians, such as whether to use one drug — or two or three drugs — in combination. Everybody knows you can use one of the 10 drugs available, but the question is, "Which one?"

This way, with mSMART, other hematologists immediately know "What would Mayo Clinic do?" mSMART gives them clarity, authoritative direction and confidence they are using the best possible treatments.

What additional help do you provide to physicians outside of Mayo Clinic for treating patients with myeloma?

First, anytime you have a doubt, pick up the phone and call us or email anytime. Second, the following are instances where you might consider referring to Mayo:

  • You'd like your patient to participate in a clinical trial unavailable to you. We have many clinical trials going on and lead many clinical trials involving 300 to 400 centers. We recently opened a new trial for newly diagnosed patients with myeloma.
  • Your patient has a particularly challenging disease. This might be a patient who's multiply relapsed, needs a stem cell transplant or is a newly diagnosed patient where you are not sure whether to start treatment, yet the disease looks suspicious.

Also, if you'd like to run an mSMART panel for your patient, Mayo Medical Laboratories provides this testing.

For more information

Rajkumar SV, et al. mSMART Stratification for Myeloma & Risk-Adapted Therapy.

Dispenzieri AS, et al. Treatment of newly diagnosed multiple myeloma based on Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART): Consensus statement. Mayo Clinic Proceedings. 2007:83;323.

Test ID: MSMRT: Mayo algorithmic approach for stratification of myeloma and risk-adapted therapy report, bone marrow. Mayo Medical Laboratories.