Introduction: Addressing Challenges in Multiple Myeloma Management in an Era of New Therapeutics
Authors: Sundar Jagannath
Journal: Journal of the National Comprehensive Cancer Network (2010)

Myeloma Management in an Era of New TherapeuticsHematologists/oncologists and other physicians can expect to encounter an increasing number of patients with multiple myeloma (MM) in the coming years.Between 1997 and 2006, the incidence rate of myeloma declined in the United States, but the burden (number of incident cases) increased. 1An analysis of population-based cancer registries in 9 countries detected modest increases in the incidence of MM in most between 1973 and 1992, with further increases projected by 2007. 2 MM remains the second most common hematologic malignancy in the United States after non-Hodgkin's lymphoma. 3istorically, MM has been a difficult and frustrating disease for patients and physicians.Since the reintroduction of thalidomide and development of lenalidomide and bortezomib, outcomes have improved considerably, particularly when these newer agents are combined with conventional chemotherapeutic agents or each other.Using the first-line regimens common in 1983, typical 2-year survival rates were 48% to 66%.In trials of triple combination therapy reported in 2008, the 2-year survival rates ranged from 83% to 90%. 4 In the United States, the 5-year survival rate improved from 26% in 1975 to 1977 to 34% in 1996 to 2003, a statistically significant difference. 5bviously, it is vitally important for today's physicians to understand the newer agents, but this is a challenge because the drugs have multiple functions (e.g., antiangiogenesis, immunomodulation, proteasome inhibition), have different toxicity profiles, and can be used in myriad combinations and sequences.Hematologists/ oncologists have indicated a need to know more about choosing first-, second-, and third-line therapies; side effects of the new agents; the role and timing of stem cell transplantation in the era of new therapies; guidelines for maintenance therapy; and what new therapeutic combinations will be major factors in treating myeloma in the coming years. [6]][8] This supplement is part of a 3-supplement series planned by myeloma experts via a roundtable discussion held April 24, 2009, in Philadelphia.Our charge was to develop outlines of 10 articles about myeloma therapy that would convey the information currently of most importance to community oncologists.The first 2 of the 4 articles in this supplement address risk reduction and management of the most common complications of myeloma therapy.Dr. Paul Richardson and colleagues focus on how thalidomide-and bortezomib-induced peripheral neuropathy usually can be effectively managed with dose reduction, schedule modification, optimized agent sequencing, or a combination of nonpharmacologic and pharmacologic therapy for symptom relief.They also discuss asthenia (fatigue), an important topic that is too infrequently addressed in myeloma reviews.The companion article, by Drs.Ruben Niesvizky and Ashraf Badros, explains the measures that oncologists should take to protect patients from a life-threatening complication, venous thromboembolism, the risk of which is elevated with thalidomide and lenalidomide.That article also reviews the latest data on osteonecrosis of the jaw, renal complications, and anemia.Dr. Badros has contributed 2 additional articles to this supplement: one on maintenance therapy and the other on defining and treating high-risk myeloma.He explains that only recently, after 3 decades of investigation, have certain maintenance regimens shown promise in myeloma.In particular, several studies suggest that thalidomide, alone or with a corticosteroid, prolongs overall survival after autologous stem cell transplantation (ASCT).However, other studies have failed to support this