Recommendations for the management, treatment and care of myeloma patients not able to undergo stem cell transplantation

This study reviewed the recommendations for the treatment and management of patients with multiple myeloma who are not able to undergo stem cell transplantation.

Multiple myeloma most frequently affects older patients. The standard treatment option is high-dose chemotherapy followed by stem cell transplantation (SCT). Some older patients may not be able to tolerate these therapies. The International Myeloma Working Group (IMWG) met in 2014 to update the treatment guidelines for patients unable to undergo SCT.

This study reviewed the IMWG recommendations.

Before treatment begins, it should be determined whether the patient is fit or unfit. This should not be based on age alone, as some older patients are more fit than others. The decision on fitness should be based on frailty and other medical conditions the patient may have. Unfit patients may also have organ dysfunction (such as heart, kidney or lung problems) and/or mental or mobility issues. Fit patients may be treated with full-dose therapy. Unfit patients need reduced intensity therapy.

Prognosis can be predicted based on multiple factors. A higher ISS stage (a measure based on multiple known risk factors) and certain chromosomal abnormalities are associated with a worse outcome. These abnormalities include t(4;14), t(14;16), t(14;20), or del17p.

Patients without symptoms are recommended to be closely monitored (every 1 to 3 months) without treatment. Patients who are symptomatic or with organ damage should start immediate treatment. The symptoms could include high levels of calcium, kidney failure, anemia (low red blood cells), or myeloma in the bone.

Very fit patients age 65 to 70, or younger patients with other medical conditions who are unsuitable for full-dose chemotherapy, may undergo reduced intensity chemotherapy with melphalan (Alkeran) followed by SCT. Very fit patients may also receive full-dose chemotherapy. In select fit patients, SCT is possible beyond the age of 65.

The recommended treatments for very fit patients include MPT (melphalan, prednisone, and thalidomide), VMP (bortezomib, melphalan, and prednisone), and lenalidomide (Revlimid) with high- or low-dose dexamethasone (Ozurdex). Lenalidomide with low-dose dexamethasone was associated with an 87% two-year survival rate, compared to 75% with high-dose dexamethasone. Unfit patients have seen improved time to disease progression with a reduced dose MPT or VMP.

Maintenance treatment is long-term treatment to reduce the risk of relapse. Thalidomide (Thalomid) is one option. This treatment, however, is associated with an increased risk of peripheral neuropathy (tingling in the hands and feet). Bortezomib (Velcade) is another option, and is associated with a lower risk of neuropathy. Lenalidomide is well tolerated, but is associated with an increased risk of secondary cancers.

Treatment for patients with relapsed disease depends on the length of the previous remission (time without active disease). Patients in remission for 20 or more months may be treated with the same treatment they received before. Relapses after shorter remissions should be treated with a different therapy. Standard options include bortezomib and dexamethasone or a type of doxorubicin, or dexamethasone and lenalidomide.

Treatment to help with symptoms and side effects is very important. Patients with bone disease should receive pain medications, as well as a bisphosphonate (treatment to improve bone strength). Radiation may also help to prevent breakdown of bone.

Dexamethasone is an effective, fast treatment option for kidney failure associated with multiple myeloma. Bortezomib can also be effective.

Patients should receive treatment to prevent low white blood cell levels (such as granulocyte colony-stimulating factor). Low hemoglobin (protein in red blood cells) can be treated with erythropoietin. Patients should also receive treatment to prevent blood clots and infection. Patients with nerve pain may benefit from treatment with nerve blockers (such as gabapentin). 

This study reviewed the recommendations for the treatment of multiple myeloma patients not eligible for SCT.