Approach to relapsed refractory myeloma

Despite tremendous advances in the initial management of patients with myeloma, now translating to at least a doubling of median overall survival in the last decade, this disease remains incurable in nearly all patients [1]. Although time to first relapse has been extended with superior induction, consolidation, and maintenance strategies, relapse is inevitable. With the emergence of many novel agents in the relapsed setting, options for providers and patients have dramatically increased. The optimal sequencing, combination, and dosing of these agents have yet to be determined. Indeed, with so many therapeutic options available, the clinician must have a rational, risk stratified and feasible to approaching patients in relapse. This chapter provides an approach to therapy for the myeloma patient with relapsed and/or refractory disease. The detailed discussion of the data for the various treatment options in relapsed disease, including Stem Cell Transplantation, New Agents, and Biologic Therapy, is covered in subsequent chapters (see Chaps. 10–13). The purpose of this chapter is to provide an overall strategy for the management of relapsed refractory disease and to help guide clinicians in selecting the most appropriate therapy for their patient. This approach emphasizes the heterogeneity of both the disease and the patient.