For newly diagnosed myeloma patients, initial treatment usually consists of induction, or front-line therapy, which is meant to decrease disease burden to a very low or even undetectable level. Exactly which induction therapy your care team will recommend depends on whether you are a candidate for autologous stem cell transplant.
Induction therapy choices (3-4 cycles of therapy):
- For transplant eligible patients:
- 3 drug regimens, including Revlimid-Velcade-dexamethasone, Ninlaro-Revlimid-dexamethasone, Kyprolis-Revlimid-dexamethasone
- Though not preferred, some patients receive Velcade-Cytoxan-dexamethasone
- A clinical trial
- For transplant-ineligible patients:
- Any of the regimens approved for transplant-eligible patients
- Darzalex-Revlimid-dexamethasone
- Revlimid-Velcade-dexamethasone lite (a lower dose of this common triplet regimen, used for frail patients)
- A 2 drug regimen such as Revlimid-dexamethasone may be considered for frail patients
- A clinical trial
For transplant-eligible patients, induction therapy is usually followed by stem cell collection and storage, high dose melphalan chemotherapy and autologous stem cell transplantation. This regimen is then followed by consolidation and/or maintenance therapy. Some patients may choose not to undergo transplantation immediately, and will go directly from induction and stem cell collection to consolidation/maintenance, reserving their stem cells for an autologous transplant procedure at a later date.
Transplant-ineligible patients go directly from induction therapy of varied length to consolidation or maintenance therapy, depending on their response to induction therapy. Your care team can help decide which course of therapy is best for you, based on your myeloma subtype and treatment goals.
After induction and autologous stem cell transplant (if eligible), patients will either undergo observation without treatment (less common) or maintenance (continuous) therapy with an approved myeloma agent. Maintenance therapy has been shown to improve progression-free survival (it can increase the length of time the patient spends in remission before they relapse) but is also associated with treatment side effects. Revlimid is an approved maintenance therapy option, but there are also clinical trials under way to study Ninlaro, Velcade, Kyprolis, Darzalex and Empliciti as maintenance therapy options.
Once patients have achieved a response (decrease in disease burden and decreased signs and symptoms of myeloma) with front-line therapy (induction, stem cell transplant and maintenance), they are closely followed by their care teams to watch for signs of relapse (loss of response to their current drug regimen) and reappearance of myeloma signs and symptoms. There are many very effective treatment options for relapsed patients, and many more being tested in clinical trials, so having a relapse should not cause loss of hope for a favorable outcome. The choice of the next therapeutic option may rest on when the relapse takes place.
Therapy choices for a first relapse that occurs less than 6 months after front-line therapy:
- Different therapy
- Autologous stem cell transplant
- Clinical trial
Therapy choices for first relapse that occurs more than 6 months after front line therapy:
- Repeat initial therapy
- Different therapy
- Autologous stem cell transplant
- Clinical trial
Therapy choices for second-line therapy may include the following drugs in combination with a steroid (dexamethasone or prednisone):
- Velcade
- Revlimid
- Kyprolis
- Empliciti
- Ninlaro
- Darzalex
If an early response is not achieved with a second-line combination therapy, or when a patient has a relapse from second line therapy, a third drug may be added:
- Pomalyst
- Farydak
- Sarclisa
- XPOVIO
Patients should also consider a clinical trial at any point in their disease journey. There are many new agents and immune therapies under investigation which may provide treatment benefit to relapsed/refractory patients. Your care team can help you find an appropriate trial. You can also use our
clinical trial finder or speak with an
MMRF patient navigator for more information.
