From the Guidelines
Multiple myeloma is a cancer of plasma cells that requires a combination approach for treatment, including chemotherapy, stem cell transplantation, and maintenance therapy, with a focus on improving outcomes and quality of life. The diagnosis of multiple myeloma is based on the presence of clonal bone marrow plasma cells, monoclonal protein in serum or urine, and myeloma-defining events such as hypercalcemia, anemia, renal insufficiency, or bone lesions 1.
Definition and Diagnosis
The definition of multiple myeloma has evolved over time, with the International Myeloma Working Group updating the criteria for diagnosis in 2014 1. The diagnosis of smoldering (asymptomatic) myeloma is based on the presence of serum monoclonal protein IgG or IgA ≥3 g/dL, Bence-Jones protein ≥500 mg/24 h, and clonal bone marrow plasma cells 10%–60% without myeloma-defining events or amyloidosis 1.
Treatment Approach
Treatment for multiple myeloma typically involves a combination of chemotherapy drugs such as bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone, often combined in regimens like VRd (Velcade, Revlimid, dexamethasone) for 4-6 cycles 1. Stem cell transplantation may be recommended for eligible patients, followed by maintenance therapy with lenalidomide 1. Newer treatments include monoclonal antibodies like daratumumab (Darzalex) and CAR-T cell therapy 1.
Supportive Care
Supportive care is essential and includes bisphosphonates for bone health, pain management, and prevention of infections 1. Regular monitoring of blood counts, kidney function, and protein levels is necessary to track disease progression and treatment response 1.
Key Considerations
Key considerations in the treatment of multiple myeloma include the patient's age, overall health, and disease stage, as well as the presence of any comorbidities or frailty 1. The Mayo Stratification for Myeloma and Risk-Adapted Therapy provides guidelines for therapy based on consensus and evidence from randomized controlled trials 1.
Recent Developments
Recent developments in the treatment of multiple myeloma have improved outcomes and quality of life for patients, with a focus on personalized medicine and risk-adapted therapy 1. Participation in clinical trials is encouraged, and patients should be enrolled in well-designed clinical trials whenever possible 1.
From the Research
Treatment Options for Multiple Myeloma
- Lenalidomide plus high-dose dexamethasone versus lenalidomide plus low-dose dexamethasone as initial therapy for newly diagnosed multiple myeloma: a study published in 2 found that lenalidomide plus low-dose dexamethasone is associated with better short-term overall survival and with lower toxicity than lenalidomide plus high-dose dexamethasone.
- Lenalidomide in combination with dexamethasone was proven to show significant clinical benefits in Phase III trials either as induction or as maintenance therapy, as discussed in 3.
- Bortezomib, lenalidomide, and dexamethasone with panobinostat for front-line treatment of patients with multiple myeloma who are eligible for transplantation: a phase 1 trial published in 4 found that the combination of VRd with panobinostat 10 mg is safe and effective in patients who are newly diagnosed with multiple myeloma and who are transplant eligible.
Maintenance Therapy
- Carfilzomib, lenalidomide, and dexamethasone or lenalidomide alone as maintenance therapy after autologous stem-cell transplantation in patients with multiple myeloma: an interim analysis of a randomised, open-label, phase 3 trial published in 5 found that median progression-free survival was 59·1 months in the carfilzomib, lenalidomide, and dexamethasone group versus 41·4 months in the lenalidomide group.
- Lenalidomide, bortezomib and dexamethasone induction therapy for the treatment of newly diagnosed multiple myeloma: a practical review published in 6 discusses the rationale for use of RVD as induction therapy and aims to provide guidance in prescribing this regimen in order to optimise efficacy while minimising the toxicities of treatment.
Combination Therapies
- The use of lenalidomide in combination with other therapies, such as bortezomib and dexamethasone, has been shown to be effective in the treatment of multiple myeloma, as discussed in 3, 4, 6.
- The addition of a monoclonal antibody to the RVD backbone may deepen responses and potentially provide longer disease control, as highlighted in 6.