Front line treatment of elderly multiple myeloma in the era of novel agents

Marie-Dominique Venon², Aldo M Roccaro^1,3, Julie Gay², Anne-Sophie Moreau^1,2, Remy Dulery², Thierry Facon², Irene M Ghobrial¹, Xavier Leleu^1,2

¹Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA; ²Service des Maladies du Sang, Hopital Huriez, CHRU, Lille, France; ³Units of Blood Diseases and Cell Therapies, University of Bresica, Medical School, Bresica, Italy

Abstract: Melphalan combined with prednisone (MP) has long been the historical treatment of reference for a large proportion of elderly myeloma (MM) patients ineligible for autologous stem cell transplantation, and is still the backbone of new regimens that include the new era of novel agents. Melphalan–prednisone–thalidomide (MPT) and melphalan–prednisone–bortezomib (Velcade^®, MPV), proved superior to MP, currently appear to be the treatments of choice for this population. In the near future melphalan–prednisone–lenalidomide (Revlimid^®, MPR) will also provide a third therapeutic option (MPT, MPV, and MPR), in elderly multiple myeloma, eventually. These options could lead to more personalized treatment approaches, based on patient comorbidities, as the three novel agents have somewhat different toxicity profiles. Dexamethasone-based regimen is another option and questions regarding the relative efficacy of melphalan-based versus low-dose dexamethasone-based regimens will require randomized phase III trials. More intensive approaches with new drug combinations or with the incorporation of polyethylene glycolated (PEGylated) liposomal doxorubicin will also require additional studies. Additionally, the important issue of maintenance treatment needs to be further investigated. These new and emerging therapies offer multiple effective treatment options for MM patients and greatly enhanced treatment strategies for clinicians.

Keywords: multiple myeloma, elderly, bortezomib, thalidomide, revlimid, IMiDs, supportive care