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Division of Hematology
Mayo Clinic
Rochester, Minnesota, USA

SUMMARY:
by Lynne Lederman, PhD

Dr. Rajkumar described the ideal frontline regimen as oral, with a manageable adverse event profile, excellent ability to allow stem cell harvest and transplant, resulting in a 100% response rate (RR), 100% survival at 4 months (allowing stem cell harvesting, although the patient may choose to stay on therapy rather than have an ASCT), and at 1 year, with an excellent long-term (5-year) survival. SCT has resulted in modestly improved survival compared with conventional chemotherapy. He suggested early transplant might result in better quality of life, although there is no phase 3 trial demonstrating that frontline transplant is better than at relapse, and the early death rate is about 10% for ASCT. Although the OS for patients receiving lenalidomide plus low dose dexamethasone is significantly higher than for those receiving lenalidomide plus high dose dexamethasone in the ECOG E4A03 trial, no response rate data are available. The Mayo Clinic suggests lenalidomide plus low dose dexamethasone as standard treatment for patients not on a clinical trial. In the relapsed setting, Dr. Rajkumar suggested using three agents, e.g., bortezomib, lenalidomide, plus low dose dexamethasone, rather than punishing patients with high dose dexamethasone added to lenalidomide or bortezomib.