ASCO GUIDELINES Bundle

Multiple Myeloma Treatment

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6 Relapsed Disease ➤ Treatment for biochemically relapsed myeloma should be individualized. Factors to consider include patient's tolerance of prior treatment, rate of rise of myeloma markers, cytogenetic risk, presence of comorbidities (i.e. renal insufficiency), frailty, and patient preference. High-risk patients as defined by high-risk cytogenetics and early relapse post-transplant/initial therapy should be treated immediately. Close observation is appropriate for patients with slowly progressive and asymptomatic relapse. (Moderate Recommendation; IC/EB-I-B) ➤ All clinically relapsed patients with symptoms due to myeloma should be treated immediately. (Strong Recommendation; EB-H-B) ➤ Triplet therapy should be administered on first relapse, though the patient's tolerance for increased toxicity should be considered. A triplet is defined as a regimen with two novel agents (proteasome inhibitors, immunomodulatory drugs or monoclonal antibodies). (Strong Recommendation; EB-H-B) ➤ Treatment of relapsed multiple myeloma may be continued until disease progression. There is not enough data to recommend risk based versus response-based duration of treatment (such as MRD). (Moderate Recommendation; EB-I-B) ➤ Prior therapies should be taken into consideration when selecting the treatment at first relapse. A monoclonal antibody-based regimen in combination with an immunomodulatory drugs and/or proteasome inhibitor should be considered. Triplet regimens are preferred based on tolerability and comorbidities. (Moderate Recommendation; EB-L-B) ➤ Autologous stem cell transplantation, if not received after primary induction therapy, should be offered to transplant eligible patients with relapsed multiple myeloma. Repeat stem cell transplant may be considered in relapsed multiple myeloma if PFS after first transplant is 18 months or greater. (Weak Recommendation; EB-L-B) ➤ The risk status of the patients should be assessed using the Revised ISS staging system for all patients at the time of diagnosis. (Strong Recommendation; EB-H-B) ➤ Repeat risk assessment at the time of relapse should be performed and should include bone marrow with FISH for myeloma abnormalities seen with progression including, 17p and 1q abnormalities. FISH for primary abnormalities (translocations and trisomies), if seen in the initial diagnostic marrow, does not need to be repeated. (Strong Recommendation; EB-H-B) Treatment

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