Multiple myeloma: the biology, the clinic and the future
The landscape of myeloma therapy has been changing quickly over the last 15 years, and when looking at drugs currently in development in clinical trials we can expect further “revolutions” in the near future. Immunomodulatory substances are at present the favored “backbones” of myeloma therapy, with new drugs like the antimyeloma antibodies evaluated in combination with lenalidomide/dexamethasone or the new oral proteasome inhibitor ixazomib evaluated in combination with thalidomide/dexamethasone. Such “chemotherapy-free” triple combinations have the potential to evolve to standards of care in relapsed disease. Just recently, a favorable outcome was reported for patients receiving therapy with carfilzomib/lenalidomide/dexamethasone when compared with lenalidomide/dexamethasone alone (ASPIRE study) and also pomalidomide was evaluated in triple combinations (e.g., combined with bortezomib/dexamethasone), with high response rates reported in relapsed/refractory disease.
In this issue of MEMO we have tried to highlight issues important for the clinician. Wolfgang and Ella Willenbacher investigate if maintenance treatment should be recommended for every myeloma patient. We know that disease eradication is not feasible in myeloma, with the exception of allogeneic transplantation (possibly). Do we need maintenance treatment to control the malignant clone? Is there a level of residual myeloma cells, under which the malignant clone loses its stromal support and stays inert? Under latter circumstances treatment intensification could be the way to go. Michael Fillitz et al. will address the question if more could be better in newly diagnosed myeloma patients. At least in younger patients, high-dose therapy with autologous transplantation seems to remain an indispensable part of first-line myeloma treatment.