Initial treatment of multiple myeloma

DRd: daratumumab, lenalidomide, low-dose dexamethasone; DVRd: daratumumab, bortezomib, lenalidomide, and low-dose dexamethasone; ECOG: Eastern Cooperative Oncology Group; FISH: fluorescence in situ hybridization; HCT: hematopoietic cell transplantation; MM: multiple myeloma; NYHA: New York Heart Association; Rd: lenalidomide plus low-dose dexamethasone; VRd: bortezomib, lenalidomide, low-dose dexamethasone.

* Risk stratification is based on results of FISH on the bone marrow for detection of t(4;14), t(14;16), t(14;20), and del17p13. FISH for 1q gain is included, if available.

¶ Eligibility for autologous HCT in MM varies across countries and institutions. In most centers in the United States, patients with one or more of the following are not considered eligible for autologous HCT in myeloma: Age >77 years, frank cirrhosis of the liver, ECOG performance status 3 or 4 unless due to bone pain, and NYHA functional status class III or IV.

Δ Single HCT is preferred for most patients. We offer double (tandem) HCT to some patients with del 17p. With this approach, a second autologous HCT is performed within six months after the completion of the first.

◊ For those initially treated with DVRd or VRd, we offer maintenance with both lenalidomide and bortezomib. For those initially treated with DRd, we offer maintenance with both lenalidomide and daratumumab.

§ The number of cycles used for an individual patient depends upon how well they tolerates the regimen and the response to treatment. If the disease continues to respond and the patient is tolerating therapy, we will offer up to 12 cycles of initial therapy.

¥ DVRd deepens responses and improves progression-free survival compared with VRd, albeit with increased toxicity and cost.

‡ An "early" HCT approach incorporates HCT into the initial treatment while a "delayed" HCT approach reserves HCT until first relapse. For patients with standard risk MM, early and delayed transplant strategies have been associated with similar survival rates. The choice between early and delayed HCT is influenced by patient preference and age, response and tolerability to the initial chemotherapy regimen, insurance approval, and institutional limitations. Refer to related UpToDate content for more details.