Assessment of Newly diagnosed Myeloma
Every newly diagnosed myeloma patient should be assessed for fitness to undergo auto-stem cell transplantation. Although some centers use an age cutoff (usually 60–65 years), it is reasonable to take performance status, organ function, and comorbidities into account, rather than age, when deciding whether a patient is eligible. Emerging data from the Arkansas Total Therapy trials suggest that the goal of myeloma therapy has changed from achieving disease control to achieving long-term disease-free survival, if not cure, in the majority of patients. In this context one should adopt a strategic approach to therapy. Enrollment of the patient in clinical trials that include auto-stem cell transplantation and that use risk stratification based on cytogenetic or gene-expression data is advisable.
Auto-stem cell transplantation for Myeloma
Four prospective randomized European studies have established that auto-stem cell transplantation confers superior overall survival and/or event-free survival when compared to standard chemotherapy therapy. Three studies did not show such benefits, but these studies can be criticized for using inferior conditioning regimens in the transplantation group, high crossover rates from the chemotherapy to auto-stem cell transplantation arm for refractory patients, and the randomization of patients after induction chemotherapy rather than initially.
Each of these studies commenced enrollment in the 1990s and, thus, were conducted prior to the introduction of novel agents such as thalidomide, lenalidomide, and bortezomib. Nevertheless, studies support the continued role for auto-stem cell transplantation in the management of myeloma in eligible patients. Vincristine, doxorubicin (Adriamycin), and dexamethasone (VAD) had long been used as the standard induction chemotherapy, but has been replaced by the advent of novel drugs. However, the optimal induction therapy prior to auto-stem cell transplantation is currently not known. Doublet and especially triplet regimens of novel drugs in combination with dexamethasone can induce complete remission rates comparable to transplantation regimens.