Current challenges in the management of patients with relapsed/refractory multiple myeloma

When treating patients with relapsed/refractory multiple myeloma, clinicians should maximize the efficacy of treatment through use of the most appropriate combinations and sequences of agents. Treatment options depend on the duration and magnitude of response to previous therapies; the type and aggressiveness of the relapse; and patient factors such as comorbidities, performance status/quality of life, bone marrow reserve, renal function, previous toxicities (eg, peripheral neuropathy, venous thromboembolism), age, insurance coverage, distance from the hospital, and life expectancy. Patients who relapse within 1 year of a stem-cell transplant (SCT) may require multidrug rescue therapy, followed by allogeneic SCT with reduced-intensity conditioning or consolidation/maintenance therapy. Those with a long duration of remission (3 to 4 years) may undergo a second autologous SCT, using the original effective treatment protocol or a different combination as reinduction. Patients with intermediate remission duration (2 to 3 years) may benefit from the sequential use of novel agents as salvage therapy. In elderly patients, considerations of quality of life and cost constraints should be carefully weighed. At first relapse, the initial option would be to use a new scheme that is different from the one used for induction, unless the first remission was long enough to merit considering retreatment with the same scheme. At second or subsequent relapse, usually after having been treated with bortezomib (Velcade) and at least one immunomodulatory drug, enrollment in a clinical trial with experimental agents should be encouraged. This article describes the current evidence available for various treatment options as well as a personal approach to individualized therapy for relapsing patients.