When a patient is newly diagnosed with multiple myeloma but cannot proceed to high-dose chemotherapy and autologous stem cell transplantation, treatment follows a distinct pathway with its own established standards of care.

Clinical Scenario

This protocol applies to patients with newly diagnosed multiple myeloma who are not eligible for high-dose therapy and autologous stem cell transplantation (ASCT). This is a large and heterogeneous population: one-third of patients are older than 75 years at diagnosis and at least 30% are classified as frail — considerations that directly influence which regimen is selected.

Treatment Approach

Multiple standard-of-care regimens are established for first-line management of this population. At first relapse, the choice of subsequent therapy is determined by which agents were used upfront — specific combination regimens are recommended according to prior treatment exposure and certain disease characteristics.

The complete structured regimen algorithm, including all options and their selection criteria, is available via the link below.

References

For patients who are not eligible for ASCT, there are three new standards of care: VRd, DaraVMP and DaraRd [I, A].
It is important to realise that one-third of patients are older than 75 years at diagnosis and at least 30% are frail.
Patients who had received a bortezomib-based therapy upfront without lenalidomide or Dara should receive an Rd-based regimen, i.e. KRd, DaraRd, IRd or EloRd [I, A].
Patients who are refractory to lenalidomide upfront could receive either PomVD, DaraKd, IsaKd or DaraVd [I, A].
VenVd is a suitable option for patients with t(11;14) who have failed lenalidomide and are sensitive to PIs [I, A], if available.

DOI: 10.1016/j.annonc.2020.11.014

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Treatment of Newly Diagnosed Multiple Myeloma Not Eligible for High-Dose Therapy

Clinical Scenario

Treatment Approach

References