INTRODUCTION The treatment of newly diagnosed multiple myeloma (MM) is rapidly evolving. The median survival of patients with symptomatic myeloma until recently was approximately 3 years with oral chemotherapy with melphalan and prednisone (MP), and approximately 5 years with high-dose therapy with autologous stem cell transplantation (ASCT). More recently, thalidomide, bortezomib, and lenalidomide, have emerged as effective agents in the treatment of myeloma. As a result, the survival of patients with MM has improved significantly. Although each of the new drugs first showed activity in patients with advanced relapsed refractory disease, they have now been successfully incorporated into initial therapy. This chapter reviews the current therapeutic options for newly diagnosed myeloma and provides a risk-based approach to the treatment of these patients. TRANSPLANT ELIGIBILITY AND RISK-STRATIFICATION The first step in the treatment of myeloma is to establish that the diagnosis is indeed MM. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering MM (SMM) are two entities that do not require any therapy that must be excluded (see Chapter 13). There is no evidence that early treatment of patients with SMM prolongs survival compared to therapy at the time of symptoms., However, clinical trials are ongoing to determine whether newer agents can delay the progression of SMM to myeloma. The next step is to determine whether the patient is a potential candidate for SCT. Transplant eligibility is determined by a variety of factors such as age, performance status, and comorbidities.
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