Short overview on the current standard of treatment in newly diagnosed multiple myeloma

Abstract

The treatment of newly diagnosed multiple myeloma has changed dramatically over the past 20 years, from near uniform application of chemotherapy to a patient performance status- and risk-based approach. Furthermore, initiation of treatment criteria have evolved from a pure end-organ damage-based definition to include risk factors of transformation to frank myeloma. Besides, the mainly cytogenetically defined Multiple Myeloma (MM) risk status, transplant eligibility of patients still serves primarily to allocate patients within a rational treatment algorithm. While all transplant-eligible MM patients should receive a triplet induction therapy followed by autologous transplantation and, in most cases, lenalidomide maintenance, other therapeutic elements (e. g., other maintenance strategies, consolidation, tandem transplantation,..) have to be decided on an individualized appraisal of risk and toxicities. Standard-risk patients should never be undertreated, as they derive the highest relative benefit from using the best available registered therapies. However, high-risk patients should be preferentially treated inside clinical trials testing additive innovative treatments, as the improvement in the prognosis of this group of patients by standard therapies has been underwhelming. Furthermore, the evaluation process of non-transplant-eligible patients should always comprise an evaluation of performance status, frailty, and comorbidities (e. g., a comprehensive geriatric assessment) to facilitate the allocation of individualized therapies.

Keywords: Multiple myeloam transplant ineligible; Multiple myeloma; Multiple myeloma 1st line therapy; Multiple myeloma transplant eligible; Multiple myeloma treatment indication.

Conflict of interest statement

E. Willenbacher, A. Balog, and W. Willenbacher declare that they have no competing interests.

Figures

Fig. 1

First-line treatment of transplant-ineligible multiple myeloma (t translocation, del deletion, V bortezomib, R lenalidomide, d low dose dexamethasone). aIn patients treated initially with Rd, continuing treatment until progression is an option for patients responding well with low toxicity. bDexametahsone is usually discontinued after 1 year. cClinical trial strongly recommended as first option. [1]

Fig. 2

First-line treatment of transplant-eligible multiple myeloma (t translocation, del deletion, V bortezomib, R lenalidomide, d low dose dexamethasone, K carfilzomib, ASCT autologous stem cell transplantation, Len lenalidomide). aIf age >65 years or >4 cycles of VRd, consider mobilization with G‑CSF plus cyclophosphamide or plerixafor. bDuration based on tolerance, consider risks and benefits for treatment beyond 2 years. cContinuing Rd for patients responding to Rd and with low toxicities. [1]