“Guidelines and how-to articles cannot possibly provide even a fraction of the knowledge that is needed to manage a complex disease with skill,” Dr Mehta explained. “It is reasonable and important for patients from smaller centers to get treated locally for convenience, but seeking an opinion at larger centers and getting their assistance with management is important.”

“We and others have done deep sequencing of tumor cells and an average patient has about 50 exome mutations; 50 genes where you see mutations that are functionally important,” said Dr Landgren. “The bottom line is, if you look at different patients, they have different mutations but there are also 15 or so genes that frequently recur.”

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The average patient with multiple myeloma has 10 tumor subtypes at any given time, typically with one that is predominant. Expertly managing that kind of disease complexity and fully appreciating its clinical implications requires levels of clinical and institutional expertise more frequently found in high-volume centers.

Dr Go believes that his team’s findings suggest that multiple myeloma fits in a larger, emerging picture of better survival among patients with less-common cancers who are treated at larger-volume facilities.

“I believe patients with cancers that are both relatively rare and complex to diagnosis or treat will benefit from being seen at a facility or doctors with higher volume of care,” he explained.

Myeloma is unique among hematological malignancies in at least one aspect, Dr Go added: “In the past 10 years, nearly a dozen new drugs, many first-in-class, were approved by the FDA [U.S. Food and Drug Administration]. Experience in using these drugs is therefore limited in the hands of most hematologist-oncologists who may see only, on average, 1-2 new myeloma cases a year.”

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“In the past, patients used to be diagnosed and then passed away after 3 years,” Dr Landgren said. “Today, there are many new medications, so having patients treated and monitored the right way, if their tumor biology is not the most aggressive subtype, their expected survival could be 10 to 20 years, which is fantastic. The future is bright.”


  1. Go RS, Bartley AC, Crowson CS, et al. Association between treatment facility volume and mortality of patients with multiple myeloma. J Clin Oncol. 2016 Oct 23. doi: 10.1200/JCO.2016.68.3805 [Epub ahead of print]
  2. Halm EA, Anderson LD, Gerber JE. Understanding the relationship between care volume and clinical outcomes in multiple myeloma. J Clin Oncol. 2017 Jan 17. doi: 10.1200/ 2016.70.4726 [Epub ahead of print]