Please select the eligibility criteria that correspond to the clinical trial below.
Title: A PHASE III, MULTI-CENTER, RANDOMIZED OPEN LABEL STUDY OF VELCADE, MELPHALAN, PREDNISONE AND THALIDOMIDE (V-MPT) Versus VELCADE, MELPHALAN, PREDNISONE (V-MP) IN ELDERLY UNTREATED MULTIPLE MYELOMA PATIENTS
Brief Summary: The proposed study will evaluate whether the combination of VELCADE, Thalidomide , Melphalan and Prednisone (V-MPT), as induction treatment for newly diagnosed elderly MM patients, improves outcomes compared to the combination VELCADE-MP.


Options:
A: Inclusion Criteria:

1. Male or female subjects 18 years or older
2. Diagnosis of multiple myeloma
3. Measurable, secretory multiple myeloma defined as serum monoclonal IgG of ≥10 g/L, serum monoclonal IgA or IgE ≥5 g/L, or serum monoclonal IgD ≥0.5g/L; or urine M-protein of ≥200 mg/24 hr
4. Relapse or progression of myeloma following prior systemic antineoplastic therapy.

Exclusion Criteria:

1. Previous treatment with VELCADE
2. More than 3 previous lines of therapy (separate lines of therapy are defined as single or combination therapies that are either separated by disease progression or by a greater than 6 month treatment-free interval)
3. Peripheral neuropathy or neuropathic pain of NCI CTCAE Grade ≥2
4. Any of the following within 3 weeks prior to randomization:

   antineoplastic or experimental therapy, corticosteroid use above 10mg a day (prednisone or equivalent), or plasmapheresis
5. Any of the following within 2 weeks prior to randomization:

   radiation therapy, major surgery (kyphoplasty is not considered major surgery)
6. Prior malignancy other than multiple myeloma diagnosed or treated within the last 2 years, with the exception of completely resected carcinoma in situ or basal/squamous carcinoma of the skin
B: Inclusion criteria:

* Confirmed diagnosis of symptomatic MM based on standard criteria.
* No prior or current systemic therapy for MM, including steroids.
* At least 18 years and less than 65 years of age.
* Presence of quantifiable M protein in serum (e.g. greater than 1 g/dL for IgG MM, greater than 0.5 g/dL of IgA or IgD MM) or urine (e.g. greater than 200 mg/day for BJ MM).
* Karnofsky performance status (PS) at least 60%.
* Willing and able to comply with the protocol requirements.
* Agreement from both male and female patients to follow the risk management program established for the prevention of pregnancy, including double methods for contraception and beta-HCG tests for women of childbearing potential and contraception for males.
* Adequate organ function, including heart, liver, kidney (serum creatinine less than 2 mg/dL)
* Platelet count at least 70 x 10/mcL and absolute neutrophil count at least 1 x 10/mcl

Exclusion criteria:

* Diagnosis of asymptomatic MM or of MGUS based on standard criteria.
* Diagnosis of non-secretory MM.
* Diagnosis of AL Amyloidosis.
* Prior or current systemic therapy for MM, including steroids (with exception of bisphosphonates).
* Patient has received other investigational drugs within 30 days before enrollment.
* Female subjects pregnant or breastfeeding
* Patient has Grade 2 or higher peripheral neuropathy (NCI criteria).
* Patient has a prior history of thrombosis or venous thromboembolism or pulmonary embolism.
* Patient has a previous diagnosis of antiphospholipid antibodies or lupus anticoagulant, factor V Leiden mutation, prothrombin G21210A mutation, antithrombin, protein C or S deficiency.
* Patient has a clear indication to receive a specific other anti-platelet therapy (e.g. clopidogrel, ticlopidine).
* Patient has a clear indication to receive long-term anticoagulant therapy (e.g. prosthetic heart valve, atrial fibrillation).
* Active bleeding or high risk of bleeding (gastrointestinal bleeding within the past 12 months; endoscopic diagnosis of peptic ulcer disease or ulcerative esophagitis within the past 6 months unless there is documented endoscopic evidence of healing; intracranial bleeding within the past year; amyloidosis; known bleeding diathesis).
* Seropositive for HIV, or active hepatitis A, B or C infection.
* Poorly controlled hypertension or diabetes mellitus (if receiving antidiabetic agents, subjects must be on a stable dose for at least 3 months before the start of therapy) or other serious medical or psychiatric conditions that could interfere with adherence to or completion of this study.
* Patient has hypersensitivity to bortezomib, boron or mannitol.
* Serious medical or psychiatric illness likely to interfere with participation in this clinical study
* Previous or concurrent malignancies at other sites, with the exception of appropriately treated localized epithelial skin or cervical cancer. Patients with remote histories (\>5 years) of other cured tumors may be entered.
* Receipt of extensive radiation therapy, systemic chemotherapy, or other antineoplastic therapy within 4 weeks before enrolment.
C: Inclusion Criteria:

* Disease Related

  * Multiple myeloma
  * Subjects must have measurable disease defined as one of the following:

    * Serum M-protein ≥ 1 g/dL
    * Urine M-protein ≥ 200 mg/24 hours
    * Serum FLC ≥ 10 mg/dL with abnormal ratio (A0 Only)
    * Quantitative immunoglobulin levels using nephelometry or turbidometry (only if protein electrophoresis was felt to be unreliable for M-protein measurement) (A0 Only)
  * Subjects must have been responsive (i.e., achieved an MR or better) to first-line, standard of care therapy
  * Refractory to the most recently received therapy. Refractory disease is defined as ≤ 25% response or progression during therapy or within 60 days after completion of therapy.
  * Subjects must have received ≥ 2 prior regimens for relapsed disease. Induction therapy and stem cell transplant will be considered as one regimen (A1 Only)
  * Subjects must have received prior treatment with bortezomib, and either thalidomide or lenalidomide
  * Subjects must have received an alkylating agent either alone or in combination with other myeloma treatments (history of stem cell transplant is acceptable) (A1 Only)
  * Subjects must have received an anthracycline either alone or in combination with other myeloma treatments, unless not clinically indicated (A1 Only)
* Demographic

  * Males and females \> 18 years of age
  * Life expectancy of more than three months
  * Eastern Cooperative Oncology Group (ECOG) Performance Status of 0-2
* Laboratory

  * Adequate hepatic function, with bilirubin less than 2.0 times the upper limit of normal, and AST and ALT of less than 3.0 times the upper limit of normal
  * Uric acid within normal range (A0 Only)
  * Total white blood cell (WBC) count ≥ 2.0 × 109/L, absolute neutrophil count (ANC) ≥ 1.0 × 109/L, hemoglobin ≥ 8.0 g/dL, and platelet count ≥ 50.0 × 109/L (A0 Only)
  * Absolute neutrophil count \> 1,000/mm3, hemoglobin \> 8.0 g/dL, and platelet count \> 50,000/mm3 (A1 Only)

    * Subjects should be platelet transfusion independent
    * Screening ANC should be independent of G-CSF or GM-CSF support for ≥ 1 week and of pegylated G-CSF for ≥ 2 weeks
    * Subjects may receive red blood cell (RBC) or platelet transfusions or receive supportive care such as erythropoietin and darbepoetin in accordance with institutional guidelines
  * Calculated and measured creatinine clearance of ≥ 30 mL/minute, calculated using the formula of Cockcroft and Gault \[(140 - Age) X Mass (kg) / (72 X Creatinine mg/dL)\]. Multiply result by 0.85 if female.
* Ethical / Other

  * Written informed consent in accordance with federal, local, and institutional guidelines
  * Female subjects of child-bearing potential must have a negative serum pregnancy test within seven days of the first dose and agree to use dual methods of contraception during and for 3 months following last dose of drug. Post menopausal females (\> 45 years old and without menses for \> 1 year) and surgically sterilized females are exempt from a pregnancy test. Male subjects must use an effective barrier method of contraception during study and for 3 months following the last dose if sexually active with a female of child-bearing potential.

Exclusion Criteria:

* Disease Related

  * Multiple Myeloma IgM (A1 Only)
  * Subjects who failed to achieve at least a confirmed MR(≥ 25% reduction in M-protein for ≥ 6 weeks) (A1 Only)
  * Subjects with non-secretory multiple myeloma, defined as \< 1 g/dL M-protein in serum and \< 200 mg/24 hr M-protein in urine
  * Subjects with disease measurable only by serum free light chain (SFLC) analysis (A1 Only)
  * Glucocorticoid therapy (prednisone \> 10 mg/day orally or equivalent) within the last three weeks
  * POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes)
  * Plasma cell leukemia
  * Chemotherapy with approved or investigative anticancer therapeutics including steroid therapy within the three weeks prior to first dose
  * Radiation therapy or immunotherapy in the previous four weeks; localized radiation therapy within 1 week prior to first dose
  * Participation in an investigational therapeutic study within three weeks or within five drug half-lives (t1/2) prior to Day 1, whichever time is greater
  * Prior treatment with carfilzomib
* Concurrent Conditions

  * Major surgery within three weeks before Day 1
  * Congestive heart failure (New York Heart Association class III to IV), symptomatic cardiac ischemia, cardiomyopathy, conduction abnormalities uncontrolled by conventional intervention, or myocardial infarction in the previous six months, LVEF \< 40
  * Acute active infection requiring systemic antibiotics, antivirals or antifungals within 2 weeks prior to first dose
  * Known or suspected HIV infection or subjects who are HIV seropositive
  * Active hepatitis A,B,or C infection
  * Non-hematologic malignancy within the past three years except a) adequately treated basal cell or squamous cell skin cancer, b) carcinoma in situ of the cervix, or c) prostate cancer \<Gleason Grade 6 with stable PSA
  * Subjects with treatment related myelodysplastic syndrome
  * Significant neuropathy (Grade 3, 4 or Grade 2 with pain) at the time of study initiation
  * Subjects in whom the required program of oral and intravenous fluid hydration is contraindicated, e.g., due to pre-existing pulmonary, cardiac or renal impairment (A1 Only)
  * Subjects with known or suspected amyloidosis (A1 Only)
  * Subjects with pleural effusions requiring thoracentesis or ascites requiring paracentesis (A1 Only)
  * Any clinically significant medical disease or condition that, in the Investigator's opinion, may interfere with protocol adherence or a subject's ability to give informed consent (A1 Only)
* Ethical / Other

  * Female subjects who are pregnant or lactating
  * Serious psychiatric or medical conditions that could interfere with treatment
D: Inclusion Criteria:

* Age \> 65 year old and not a candidate for stem cell transplant, or younger who refuses or is not eligible for high-dose therapy
* Symptomatic multiple myeloma or asymptomatic multiple myeloma with related organ or tissue damage
* Presence of measurable disease
* Karnofsky performance status (PS) \> 60%
* Able to read and complete the HRQOL instruments
* Agrees to use an acceptable barrier method for contraception for the duration of the study
* Pretreatment clinical laboratory values within 14 days of randomization:

platelet count ≥ 100x109/L

* hemoglobin ≥ 8 g/dL
* absolute neutrophil count (ANC) ≥ 1.0x109/L
* AST ≤ 2.5 times the upper limit of normal
* ALT ≤ 2.5 times the upper limit of normal
* total bilirubin ≤ 1.5 times the upper limit of normal
* serum creatinine ≤ 2.5mg/dL
* corrected serum calcium \<14 mg/dL (\<3.5 mmol/L)
* Subjects (or their legally acceptable representatives) must have signed an informed consent document indicating that they understand the purpose of and procedures required for the study and are willing to participate in the study.
* Women of child-bearing potential must agree to use 2 methods of contraception: 1 effective (for example hormonal or tubal ligation) and 1 barrier (for example latex condom, diaphragm) for at least 4 weeks before starting the therapy, during the Treatment Period, and for 4 weeks after the last dose;
* Males must agree to use barrier contraception (latex condoms) when engaging in reproductive activity during the Treatment Period and for 4 weeks after the last dose.

Exclusion Criteria:

* Diagnosis of smoldering multiple myeloma or MGUS.
* Diagnosis of Waldenstrom's disease
* Prior or current systemic therapy for multiple myeloma including steroids (with exception of emergency use of a short course \[maximum 4 days\] of steroids before randomization or prior or current use of biphosphonates)
* Radiation therapy within 30 days before randomization
* Plasmapheresis within 30 days before randomization
* Major surgery within 30 days before randomization (Kyphoplasty is not considered major surgery)
* History of allergic reaction attributable to compounds containing boron or mannitol, or to Thalidomide
* Peripheral neuropathy Grade 2 or higher, as defined by National Cancer Institute Common Toxicity Criteria (NCI CTC) 3.0
* Uncontrolled or severe cardiovascular disease including myocardial infarction within 6 months of enrollment, New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina, clinically significant pericardial disease, or cardiac amyloidosis
* Other malignancy within the past 5 years. Exceptions: basal cell or non metastatic squamous cell carcinoma of the skin, cervical carcinoma in situ or FIGO Stage 1 carcinoma of the cervix
* Concurrent medical condition or disease (e.g., active systemic infection, uncontrolled diabetes, pulmonary disease) that is likely to interfere with study procedures or results, or that in the opinion of the investigator would constitute a hazard for participating in this study
* Use of any investigational drugs within 30 days before randomization.
* Pregnant or lactating women. A serum β-hCG pregnancy test must be performed at the Screening visit, for female patients of child-bearing potential. If the test is positive, the patient must be excluded from the study. Confirmation that the patient is not pregnant must be established by a negative serum or urinary pregnancy test with the result obtained 1 day prior to the Baseline visit (or the day of the visit if results are available before drug delivery).

Answer: D