Combination chemotherapy

• ABCM (fflp620),VMCP/VBAP and VBMCP showed improved objective responses in 3 large studies; CR still <10%; but no survival benefit over M&P on meta-analysis; 'superior results in younger patients with poor risk disease; side effects myelosuppression and infection; more toxicity in elderly patients.

• VAD infusional regimen (fflp624) produces improved overall responses (60-80%) and CRs (10-25%); maximum response rapidly achieved (~12 weeks); responses not durable without consolidation by melphalan-containing regimen; non-toxic to stem cells thus good initial therapy in patients destined for PBSC harvest, HDT and autograft; useful regimen in patients with renal failure; VAMP gives similar results; no convincing advantage for C-VAMP (fflp622); side effects myelosuppression, infection (esp. indwelling IV catheter), alopecia, neuropathy, proximal myopathy (add PPI or H2 antagonist).

Approach to treatment of myeloma in non-trial patients

Age >65 years M&P to plateau

Repeated on progression if durable response to initial therapy

Thal-Dex or low dose CTX for short response/ refractory disease

Age <65 or very fit >65 VAD x 4-6; PBSC mobilisation; HDM; repeat on progression if durable response; Thal-Dex for short response/refractory disease

Thal-Dex, thalidomide + dexamethasone; CTX, cyclophosphamide.

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